Job Description

The Corporate Compliance and Business Ethics Group’s (CCBEG’s) Privacy Program provides privacy oversight, subject matter expertise, support, and guidance to all administrative and clinical functions with the University of Maryland Medical System (UMMS) and is based on the seven elements of an effective compliance program adhering to industry regulations, system policies, the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation, Conditions of Payment and state specific requirements.

Under the supervision of the Director, will manage complex privacy incidents, develop, implement, and monitor privacy policies, procedures and processes, manages the privacy audit and monitoring plan and related management action plans, and ensure compliance with existing and new federal and state privacy laws and regulations affecting UMMS. Additionally, will work collectively with UMMS Member Organizations (e.g. hospitals) management and other personnel to ensure that Corporate Privacy Program initiatives are implemented across UMMS.

Principal Responsibilities and Tasks

The following elements are intended to provide a comprehensive overview and level of work performed by the individual assigned to this job description. The elements are not an exhaustive list of all the job duties the assigned individual may be requested to perform.

Principal responsibilities of a Privacy Analyst include:

Serves as the privacy resource to UMMS Corporate and Member Organizations, building strong cross-functional relationships with Shared Service and Member Organization leadership advising on privacy-related issues.

Serves as the information privacy resource to the organization regarding release of information and to all departments for privacy related issues.

Lead role for managing and resolving complex privacy investigations received through internal reporting methods, collaborating with internal and external key stakeholders and Member Organizations to determine resolution and manage breach determination and notification process under Health Insurance Portability and Accountability Act (HIPAA) and applicable state privacy rules and regulations.  Conduct root cause analysis, facilitate management action plan and oversee implementation.

Lead role for managing and resolving privacy inquiries and investigations received from regulatory agencies such as the Department of Health and Human Services (HHS) Office for Civil Rights (OCR) and HHS Office of Attorney General (OAG).  Privacy Analyst is responsible for responding to federal or state regulators, collaborating with key stakeholders to address privacy inquiries, or investigate the complaint, drafting applicable investigation reports, facilitates development of management action plans, and drafting response to the regulatory agency with supporting documentation.

Prepares and submits federal and state privacy breach reports for UMMS under the direction of Director of Privacy and Research Compliance.

Manages tracking of current, revised, and new federal and state privacy laws.  Provides status reports to CCBEG leadership on regulation and impact on UMMS. Develops and manages project plans with action steps to comply with regulatory changes and serves as lead collaborating with organization key stakeholders and member hospitals on regulatory change implementation and education. Conducts audits/reviews and performs analysis to determine compliance with applicable federal and state laws, and policies and procedures.

Manages the Privacy Audit and Monitoring Plan for the organization. Drafts and implements annual Privacy Audit and Monitoring Plan, develops auditing tools and tool-kits, collaborates with Member Organizations to implement audit and monitoring activities and performs quality assurance reviews as requested by the Director of Privacy and Research Compliance and provides applicable recommendations.  Develops, prepares, and presents audit and monitoring outcome reports with recommendations for improvement and remediation to CCBEG leadership.

Reviews the investigation and breach risk assessment works of Member Organizations and Compliance Analysts.

Mentor and guides Compliance Analysts.

Manages and develop privacy policies and procedures

Monitors investigation and inquiry data and trends to determine deficiencies and/or areas for further investigation and provides recommendations for operational changes and education opportunities.

Develops privacy awareness messages and education materials in collaboration with the Director of Compliance and Director of Compliance Education, Regulatory, and Monitoring.

Prepares reports to meet the needs of the Chief Compliance Officer, Vice President of Compliance Operations, Director of Compliance, UMMS Executive Management, and the Audit and Compliance Committee of the Board of Directors.

Perform other duties as assigned.