Director Compliance - St Vincent Regional Medical Center
CHRISTUS Health
Application
Details
Posted: 22-Nov-24
Location: Santa Fe, New Mexico
Internal Number: 207169
Description
Summary:
The Compliance and Risk Director is responsible for managing all requirements related to Information Management Regulatory/Compliance. This position manages all activities related to the development, communication and management of policies, controls and practices supporting IT compliance, regulatory and risk objectives. Tracks, tests, and reports on audit and assurance practices for Information Management to identify points of vulnerabilities and recommend quality measurement and improvement strategies to meet regulatory requirements.
Responsibilities:
Audit management and facilitation ? Facilitate internal and external IT audits and certifying agency activities, insuring timely response. This includes supporting discovery and testing phases, creating compliance maps of current practices/policies to standards, and coordinating responsibility of follow through for remediation activities. Maintains monthly management level status reporting of progress. Maintain a schedule of testing for critical risk areas.
Compliance/Risk management- Develop and maintain necessary guidelines, standards and procedures in support of the information security and regulatory compliance such as HIPAA, E-Discovery, Security Assurance, and JCAHO. Provide oversight and expert consultation to Associates seeking guidance on application of compliance and information security standards. Maintain a risk register with up to date research on changing regulatory requirements and insures information distributed with IM management with relevant areas of impact identified.
Disaster Recovery / Business Continuity ? Manages the execution of the Disaster Recovery program insuring program goals are met within approved parameters. Insures appropriate documentation is maintained and retained for appropriate time periods.
Compliance and Security Controls ? Manages the quality assurance processes and audits to insure appropriate access controls are in place, providing recommendations and feedback to the Security team.
Vision and Strategy ? Provide input into the Quality and Risk Program vision and strategy of the organization, supporting the IM strategic plan and continuous improvement plan.
Program Leadership - Develops and initiates specialized education and development of materials to support Regional HIPAA Security Officers.
Budget & Financial Administration - Develop and manage detailed budgets, tracking all capital and operational expenditures and regularly reporting the budgetary status of all assigned project budgets including hardware, software and support components.
Project Management - Plans, prioritizes, manages and schedules multiple large, complex projects, often overseeing multiple efforts and coordinating activities of other project managers. Assigns technical, supervisory, administrative and financial resources to meet approved corporate and regional project schedules and goals.
Communication ? Provide effective oral and written communications to staff to facilitate understanding, ownership and accomplishment of project goals and objectives. Demonstrate strong interpersonal skills, possess good negotiating skills and promote teamwork among subordinates.
Standards ?Provide expert consultations and lead in the development and documentation of procedures and standards that ensure accurate evaluation of the IM Audit and Risk standards required for support of clinical, business and technical processes.
Contract Negotiations ? Assist in the negotiation of contracts for the acquisition of relevant program related services, including software, hardware and support services, following established processes.
Reporting ?Prepares quarterly risk reports with appropriate risk register, risk awareness alerts, audit indices and trends for IM Leadership review.
Support - Interface with IM management to understand their business and service needs and develop processes for IM implementation to accommodate them.
Teamwork ? Maintain and demonstrate good teamwork on assigned projects through actions and job performance.
Other ? Perform other duties and special projects as assigned by the Director.
Requirements:
Bachelor's Degree
Work Type:
Full Time
EEO is the law - click below for more information:
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact us at (844) 257-6925.
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.
We’re here to answer your product-related questions
NAHQ wants to partner with you and your organization as you explore how to elevate the profession and advance the discipline of healthcare Quality & Safety.
Need customer service assistance?
For customer service issues, contact us at info@nahq.org or call us at (847) 375-4720. The team is available Monday-Friday from 8 AM-4:30 PM CT.
Important Information for CPHQ Recertification
The recertification process has been streamlined. Unlike previous years, you don’t need to list out your CE activities at the time of completing your application. Instead, you will be asked to attest to having met the requirements, further aligning with the honor-based system of recertification. In the event that your application is randomly selected for audit, you may be required to list your CE activities and submit supporting documentation.
While you may participate in NAHQ learning opportunities (Learning Labs, JHQ articles, etc.), you can only claim CE credit once for each activity. Therefore, if you’ve previously earned CE from a NAHQ learning opportunity, you can’t claim it again, nor will you see the repeat CE appear in your “My Learning� tab. This includes activities used in previous recertification cycles.
Remember, if you’re recertifying during the grace period (1/1/24-1/31/24), you already had to earn your CE hours by Dec 31, 2023.
You still have time! Register today for a multi-day virtual event that addresses the most urgent and important issues facing healthcare today that offers a full schedule of educational sessions organized around NAHQ’s twice-validated healthcare quality competency framework.
We are excited to announce the release of the book “UNSTOPPABLE: Inspiring Stories of Perseverance, Triumph and Joy from Trailblazing Women in Healthcare“.
Be inspired by nine leading healthcare trailblazers, including our own CEO Stephanie Mercado, who empower us all with their vision and passions.
You’ll notice we’ve simplified the application process to recertify. You will not have to list your CE activities at the time of applying*. Simply attest that you met the requirements to complete the application.
*In the event of an audit, CPHQs may need to list activities and upload documentation in their NAHQ account.
Quality Education Resources
Join this informative session, “Quality Education Resources� Thursday, June 22 from 11-11:30 a.m. CT. You will learn about the range of NAHQ quality education resources available to you and hear directly from universities about the benefits they realized from implementing NAHQ’s content within their courses.
Maintain a Pulse on the Latest Quality & Safety Benchmarking Data
Learn more about NAHQ’s enhanced Quality and Safety Benchmarking Program, which provides timely insights to help U.S. hospitals and health systems create data-driven business cases for their quality and safety resourcing.
Understand the Variability Among Your Quality Team Through Workforce Accelerator
Join us Tuesday, May 2, at 11 a.m. CT, to learn more about the different options available to engage with NAHQ’s enterprise-wide solution, Workforce Accelerator®. Options range in size and scope and are designed to meet the various budgetary and timing needs of health systems as they embark on their quality journeys. Register today!
Healthcare Quality and Safety Workforce Report: New Imperatives for Quality and Safety Mean New Imperatives for Workforce Development
The National Association for Healthcare Quality® (NAHQ) has conducted groundbreaking research on the advancement of the quality and safety agenda and has published the results in a new workforce report. NAHQ’s Healthcare Quality and Safety Report answers the question: “Is today’s healthcare workforce doing the work that will advance critical priorities of quality, safety, equity, value, and system sustainability?� The answer is no.
Updated Maintenance Dates: Sunday, February 5, 2023
Maintenance is planned for Sunday, February 5, from 11 p.m.-4 p.m. CT. During this time, you will not have access to the “My Learning” section of your NAHQ account. We apologize for any inconvenience this may cause and thank you for your patience.
NAHQ’s Organizational Membership Subscription will serve as a one-stop shop for healthcare quality and safety training and education. Attend the February 2, at 11 a.m. CT, info session to further understand the new offering that will continue NAHQ’s focus of “Quality in Action.�
NAHQ has published an updated version of the CPHQ exam content outline.
The new exam content will take effect on March 15, 2023. Candidates planning to take the exam before March 15, 2023, can access the current CPHQ exam content outline and related resources on our website.
Missed NAHQ Next? Don’t worry, you can purchase NAHQ Next on-demand and receive access to all content for 60 days from purchase. Benefit from actionable content that addresses issues head-on and features “how-tos” and results. Buy now and have the opportunity to receive 40+ CEs.
Healthcare Quality and Safety Workforce Report: New Imperatives for Quality and Safety Mean New Imperatives for Workforce Development
Member Briefing Workshop and Healthcare Quality Week Webinar
October 7, at 12 p.m. CT
NAHQ will host an exclusive member briefing workshop where NAHQ CEO Stephanie Mercado and NAHQ President-Elect Nidia Williams will review the workforce report in-depth and prepare you to discuss it with your team and leadership during Healthcare Quality Week.
October 17, at 12 p.m. CT
To kick off Healthcare Quality Week, (HQW) NAHQ will host a complimentary webinar with NAHQ leaders to discuss the report, its impact and how you can leverage the report to your advantage.
You still have time! Register today for a multi-day virtual event that addresses the most urgent and important issues facing healthcare today that offers a full schedule of educational sessions organized around NAHQ's twice-validated healthcare quality competency framework.