Compliance and Privacy Manager - Counsel

The Compliance and Privacy Manager oversees, in pertinent part, the following compliance risk areas:  (i) general compliance and compliance program effectiveness; (ii) fraud, waste and abuse and Deficit Reduction Act of 2005 workforce member and contractor compliance;  (iii) patient and employee confidentiality, organizational privacy, information governance, and data risk classification; (iv) accountable care organization compliance; (v) Medicare C & D/Medicare Advantage compliance program requirements; (vi) Federal healthcare program compliance; and (vii) other assigned risk areas identified through organizational experience, risk identification activities, or regulatory mandates.


 

• The Manager will support the Director of Corporate Compliance to ensure implementation of appropriate policies and procedures, support compliance training, conduct investigations.
• Perform compliance program effectiveness reviews based on the seven (7) elements of an effective compliance program as set forth in: (i) relevant U.S. Department of Health and Human Services compliance program guidance; (ii) U.S. Sentencing Commission Guidelines Manual; (iii) U.S. Department of Justice, Criminal Division, compliance program guidance; (iv) CMS Conditions of Participation; (v)  Medicare Shared Savings Program Accountable Care Organization Compliance guidance and regulatory requirements; and (vi) Medicare C & D/Medicare Advantage compliance program requirements.
• Maintain a system of reporting and ensure the integrity of all compliance investigations, direct and coordinate internal audits, and monitor HIPAA/Patient Privacy compliance.
• The Manager ensures that the Compliance Program effectively promotes prevention, detection, and resolution of instances of improper conduct to ensure conformity to state or federal laws, regulatory requirements, hospital policies, patient privacy, IT Security or the standards of conduct.
• The Manager will be responsible for following up on reported incidents of non-compliance, conduct and or coordinate internal investigations and prepare reports on the incidents and investigation findings.
• The Manager will be responsible for assessing compliance of the organization's policies and assist in updating or developing new policies.
• The Manager will assist in evaluating areas of potential billing, Stark, Anti-kickback compliance or patient privacy risk and collaborate with other managers within the organization to work with management to implement solutions to eliminate potential risks.
• Manage and investigate compliance questions, complaints, and reported incidents in collaboration with management, legal and human resources, as needed.
• Responsible for Compliance Program data analytics to develop reports for monitoring and auditing, case management and federal reporting.
• Responsible for developing organizational wide compliance communication plan, communications, and training programs.           
• Coordinate HIPAA Security compliance activities with the AH HIPAA Security Officer/Information Security Officer.
• Investigate HIPAA-related complaints and draft corresponding reports.
• Draft responses to HIPAA-related regulatory inquiries.
• Review business associate agreements, data use agreements, and limited data set agreements and ensure said agreements are acceptable as to compliance form and meet standard form internal requirements.
• Conduct risk assessments and audits pertaining to assigned compliance risk areas.
• Conduct compliance and privacy training and education.
• Prepare PowerPoints and present educational or compliance-related topics to AH constituents.
• Draft compliance and HIPAA-related policies and procedures, as well as policies and procedures related to other assigned risk areas.
• Assist in conflict-of-interest reviews, evaluations, and determinations.
• Assist in conflict-of-interest endorsement requests reviews.

 

Qualifications:

• Education:  A Juris Doctor degree from an ABA accredited law school and admission to the bar to practice law in one of the 50 States (or Washington, D.C.) of the U.S.  is required.  The holding of a Master’s Degree in public health, healthcare, accounting, allied health, clinical-related studies, compliance, audit, computer science, finance, education, law, privacy, information security, information governance, or another field related to the responsibilities of the position at hand, is a plus.

• Certifications: Candidates who hold the “CCEP” or “CHC” designation from the Compliance Certification Board are strongly preferred.  Any successful candidate who does not hold the “CHC” designation at the time of appointment will be required to obtain the same within 12 months of appointment.    A successful candidate must obtain either the “CISA”, “CRISC”, or “AAIA” designation from ISACA within eighteen (18) months of employment.

Experience:

• Five years minimum of health care compliance experience, health care administration, legal, fraud, waste, and abuse; internal audit, organizational compliance, regulatory affairs or a filed related to the responsibilities of the position at hand, is preferred.

• Experience in conducting compliance investigations, legal internal investigations, or similar investigations is required;
• Managerial experience in a healthcare organization or related setting is preferred.

Technical:

• Proficiency in Microsoft Word, Excel, PowerPoint.

Other Required Skills

• Demonstrated current knowledge of business ethics, legal and compliance risks.
• Advanced and highly developed communication and influencing skills.
• Excellent writing skills.#LI-AW1

At Atlantic Health System, our promise to our communities is; Anyone who enters one of our facilities, will receive the highest quality care delivered at the right time, at the right place, and at the right cost. This commitment is also echoed in the respect, development and opportunities we give to our more than 20,000 team members. Headquartered in Morristown, New Jersey, we are one of the leading non-profit health care systems in the nation. Our facilities and sites of care include:

• Morristown Medical Center, Morristown, NJ
• Overlook Medical Center, Summit, NJ
• Newton Medical Center, Newton, NJ
• Chilton Medical Center, Pompton Plains, NJ
• Hackettstown Medical Center, Hackettstown, NJ
• Goryeb Children's Hospital, Morristown, NJ
• CentraState Healthcare System, Freehold, NJ
• Atlantic Home Care and Hospice
• Atlantic Mobile Health
• Atlantic Rehabilitation

We also have more than 900 community-based healthcare providers affiliated through Atlantic Medical Group. Atlantic Accountable Care Organization is one of the largest ACOs in the nation, and we are a member of AllSpire Health Partners.

We have received awards and recognition for  the services we have provided to our patients, team members and communities. Below are just a few of our accolades:

• 100 Best Companies to Work For ® and FORTUNE® magazine for 15 years 
• Best Places to Work in Healthcare - Modern Healthcare
• 150 Top Places to work in Healthcare - Becker's Healthcare
• 100 Accountable Care Organizations to Know - Becker's Hospital Review
• Best Employers for Workers over 50 - AARP
• Gold-Level "Well Workplace": Wellness Council of America (WELCOA)
• One of the 100 Best Workplaces for “Millennials” Great Place to Work® and FORTUNE® magazine
• One of the 20 Best Workplaces in Health Care: Great Place to Work® and FORTUNE® magazine
• Official Health Care Partner of the New York Jets
• NJ Sustainable Business 

Atlantic Health System offers a competitive and comprehensive Total Rewards package that supports the health, financial security, and well-being of all team members. Offerings vary based on role level (Team Member, Director, Executive). Below is a general summary, with role-specific enhancements highlighted:
Team Member Benefits

• Medical, Dental, Vision, Prescription Coverage (22.5 hours per week or above for full-time and part-time team members)
• Life & AD&D Insurance.
• Short-Term and Long-Term Disability (with options to supplement)
• 403(b) Retirement Plan: Employer match, additional non-elective contribution
• PTO & Paid Sick Leave
• Tuition Assistance, Advancement & Academic Advising
• Parental, Adoption, Surrogacy Leave
• Backup and On-Site Childcare
• Well-Being Rewards
• Employee Assistance Program (EAP)
• Fertility Benefits, Healthy Pregnancy Program
• Flexible Spending & Commuter Accounts
• Pet, Home & Auto, Identity Theft and Legal Insurance

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Note: In Compliance with the NJ Pay Transparency Act (effective Sunday, June 1, 2025), all job postings will include the hourly wage or salary (or a range), as well as this summary of benefits. Final compensation and benefit eligibility may vary by role and employment status and will be confirmed at the time of offer.
EEO STATEMENT
Atlantic Health System, Inc. is an equal employment opportunity employer and federal contractor or subcontractor and therefore abides by applicable laws to protect applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment, on the basis of race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, citizenship status, disability, age, genetics, or veteran status.