Job Description

Job responsibilities - Senior Compliance and Privacy Manager

• Responsible for all aspects of the organization's corporate compliance and ethics program and associated fraud, waste, and abuse prevention initiatives
• Investigate compliance issues, recommend corrective action, follow-up for implementation. Maintain a system of reporting and ensure the integrity of all compliance investigations, direct and coordinate internal audits, and monitor HIPAA/Patient Privacy compliance.
• Manage the day-to-day activities of the Compliance Division of the AHS Corporate Compliance and Internal Audit Department
• Develop and update written internal standards of conduct and associated policies, procedures, and guidance pertaining to the implementation of the AHS Compliance and Ethics program and related fraud, waste, and abuse prevention initiatives
• Oversee the maintenance of the organizational-wide compliance reporting process and associated organizational-wide confidential and anonymous compliance hotline
• Responsible for compliance with HIPAA Privacy and Breach Notification Rules and applicable State privacy law pertaining to patient information, employee information, and protected personally identifiable information; data breach determinations and follow up; investigations; risk assessment and analysis; internal and external reporting; HIPAA training framework and program; and digital privacy compliance-related matters
• Develop and conduct organizational-wide compliance-related training and education for AHS new team member team member orientation, as well as for annual and ad hoc compliance training
• Develop vendor management compliance program;
• Develop and revise: (i) compliance and ethics program charter; and (ii) compliance plan.
• Conduct annual compliance program effectiveness reviews;
• Develop Accountable Care Organization compliance program;
• Draft, revise, and negotiate business associate agreements;
• Review FCPA and OFAC contractual provisions, as necessary;
• Develop and perform focused audit-related activities including, without limitation, the conduct of compliance reviews, the assessment of existing internal controls, and the performance of gap analyses, concerning organizational risk areas (whether such risks are predefined by regulation or regulatory guidance, or identified through organizational experience) for legal and regulatory compliance
• Identify compliance risks based on, among other things, applicable law, healthcare industry best practices, organizational threats and vulnerabilities related to compliance risk areas, and State and Federal compliance work plans. As requested by, and in consultation with, the Director of Internal Audit and ERM, assist, as necessary, in the development of assessment of organizational-wide risks, including risk identification, scoring, prioritization activities; and championing, coordination, and facilitation of enterprise risk management activities.
• Conduct, manage, and document investigatory activities in response to compliance-related and privacyrelated complaints and concerns
• Perform effectiveness assessments of the AHS Compliance Program
• Oversee the Medicare C & D compliance program;
• Oversee Organized Delivery System compliance;
• Conduct facility and medical provider compliance committees as assigned;
• Oversee compliance with the Employee and Contractor Education provisions of the Federal Deficit Reduction Act of 2005 ('DRA") and corresponding New Jersey DRA requirements;
• Serve as a subject matter expert for Stark, Anti-kickback, Civil Monetary Penalties Law; and conflicts of interest issues
• Provide general compliance support to the organizations accountable care organization
• Support the review, negotiation and drafting of business associate agreements

Qualifications

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 or the ability to be admitted by July of 2026. 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:
• Six 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.

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.

About the Team

Atlantic Health System is at the forefront of medicine, setting standards for quality health care powered by a workforce of more than 18,000 team members and 4,800 affiliated physicians dedicated to building healthier communities, the system offers more than 400 sites of care, including eight award-winning medical centers. Specializing in cardiovascular care, cancer care, orthopedics, neuroscience, pediatrics, women's health and rehabilitation medicine. Atlantic Medical Group, comprised of 1,000 physicians and advanced practice providers, represents one of the largest multi-specialty practices in New Jersey and includes finance, legal, marketing, human resources, talent acquisition, ISS and more. Caring for our patients, our team members and the communities we serve is our central mission.