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Compliance & Risk Analyst II

CHRISTUS Health Irving Full-Time
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Description

The Compliance and Risk Analyst is responsible for participating in efforts of measuring compliance and measuring risk throughout the Info'illation Management organization (IM). The Analyst must be familiar with and keep up-to-date with regulations, rules, and standards related to information and system control practices. The individual must understand strategic compliance goals in order to assist in the assessment and implementation of effective and efficient controls and processes. Such are designed to ensure compliance and mitigate risk throughout the IM organization. Detailed technical knowledge of healthcare industry applications in a multi-facility environment is critical in this position. The Analyst is also responsible for advising, training, and assisting customers in the analysis and development of internal controls of their systems. In addition, the Analyst is responsible for delivering quality and cost-effective solutions to all levels of users including support for both technical and functional processes. The Analyst is also responsible for supporting the business goals and objectives for the Department, the Information Management Organization, and the CHRISTUS Health organization as a whole.

MAJOR RESPONSIBILITIES:

  • Internal and External Audit Liaison
    • Works closely with both audit organizations.
    • Supports IM counterparts to under control concerns and implement corrective action.
    • Ensures that internal controls are represented in our guidelines/procedures and processes.
  • Compliance
    • Understands governing bodies including healthcare industry regulators/accreditors, Corporate guidelines, procedures and directives, and industry best practices (e.g., ITIL, COBIT, etc.).
    • Remains current through formal and self-education efforts.
    • Assists corporate and regional IM with compliance readiness and responses to audit requests (e.g., The Joint Commission, CMS, etc.).
  • Disaster Recovery Planning (DRP)
    • Participates in periodic review of Business Impact Assessments (BIAS).
    • Facilitates the development, testing and implementation of DRP plans.
    • Assesses plans on a periodic basis to ensure they are current and viable.
  • IM Guidelines and Procedures
    • Assists with efforts to assess compliance through scheduled periodic reviews.
    • Reviews documents to ensure they are current and representative of current processes.
  • Project Controls
    • Participates in high priority projects to ensure proper control.
    • Evaluates project plans to ensure the adequacy, effectiveness and proper completion of checkpoint controls (i.e., requirements, test result, approvals, etc.).
    • Ensures that our project life cycle includes considerations for impact on DRP, guidelines and procedures, and regulatory/accreditor compliance.
    • Reviews evidence supporting the project effort to ensure properly maintenance and retention for audit/compliance purposes and future reference.
  • Asset Management
    • Evaluates internal controls designed to assure properly accountability of assets in our financial and asset management systems.
  • Due Diligence Reviews
    • Performs periodic reviews to ensure compliance with established guidelines and procedures to ensure:
    • Timely review and maintenance of IM guidelines and procedures.
    • Proper maintenance of regulatory response materials (e.g., The Joint Commission, LabCap, etc.).
    • Effective monitoring of internal and external audit deficiencies/observations ensuring that corrective action is timely, effective and sustainable.
    • DRP plans are developed, current, properly maintained and tested periodically to assure plan viability and sustainability of the IM operations.
    • Documents supporting SDLC efforts are properly prepared and retained in support of critical projects.
    • Compliance with third-party preventive and remedial maintenance of clinical equipment (e.g., Crothall).
    • Proper accountability of assets and proper destruction of assets in compliance with IM guidelines/procedures and third-party contractual terms (e.g., Arrow/Redemtech).
  • General
    • Keeps abreast of developments, regulation, rules and standards associated with the healthcare industry.
    • Participates in the development of processes and procedures to meet regulatory and technical control requirements.
    • Communicates effectively with technical and functional representatives on risk and compliance concerns.
    • Participates in meetings, identifies opportunities and makes recommendations to improve control related processes.
    • Analyzes and recommends control standards and best practices to enhance the IM Compliance and Risk function.
    • Manages personal workload related to open issues and requests for service to ensure requirements are met.
    • Demonstrates strong communication, human relationship skills, while maintaining and demonstrating good teamwork through actions and job performance.
    • Provides effective customer service by being courteous, polite and friendly at all times.
    • Completes assigned training courses within HealthStream, other electronic tracking tools for educational related material or attend presentations as required.
    • Ensures the services that he/she provides contribute to the successful accomplishment of the primary mission of the department.


Requirements
  • Bachelor degree in computer or audit or related field preferred or equivalent experience.
  • Knowledge of healthcare standards related to regulation and accreditation.
  • Project Management and life cycle controls.
  • Strong verbal and written communication skills.
  • Understanding and applying control concepts and terminology.
  • Audit and investigative skills.
  • Patience and strong customer service skills.
  • Ability to multi-task.
  • Effective time management.
  • Works cooperatively with others.
  • Five years of hands-on experience in info' nation systems audit/assurance, compliance and/or risk management.
  • preferred Certified Information Systems Auditor, but not required.
 

Skills required

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Assets
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Job ID: 5000479390506

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The two Congregations of the Sisters of Charity of the Incarnate Word in Houston and San Antonio share a common mission of providing the healing ministry of Jesus Christ, which began more than 130 years ago. The shared legacy of the two Congregations dates back to 1866 when three Sisters Religious came from France in response to a call from Catholic Bishop Claude M. Dubuis to come to Texas to help care for the sick and infirm. In the leading port city of Galveston, the Sisters founded the Congregation of the Sisters of Charity of the Incarnate Word and opened the first Catholic hospital in the state. In 1869, three members of the Congregation traveled to San Antonio and established Santa Rosa Hospital. Due to the distance between the cities and the problems of transportation at the time, the Congregation in San Antonio became a separate order with the same name as its founding Congregation.

The Congregations of the Sisters of Charity of the Incarnate Word in San Antonio and the Sisters of Charity of the Incarnate Word in Houston announced in September of 1997 their plans to work together toward combining the health care systems which each sponsors. In July 1998, the two signed a letter of intent, calling for all assets of the Sisters of Charity Health Care System (SCH) and the Incarnate Word Health System (IWHS) to become part of CHRISTUS Health. On February 1, 1999, that dream became a reality and CHRISTUS Health was born.

The Legacy

In 1972 Space Center Memorial Hospital opened to serve the 55,000 community members surrounding NASA Manned Spacecraft Center. The goal of the new hospital was "to return to the people of our country the benefits in the form of health service dividends produced from space exploration."

Unfortunately, the facility was closed in September 1974, only 13 months after it opened, by the Federal Housing Administration because the hospital was behind in mortgage payments. The hospital was unoccupied until the federal government took it over.

In 1981 Congress passed an administration bill, part of President Reagan’s budget-cutting proposals, that closed eight Public Health Service hospitals in the United States. The Houston-based Sisters of Charity of the Incarnate Word Health Care Systems was selected by the federal government to assume control of the U.S. Public Health Service Hospital in Nassau Bay. The government said Sisters of Charity was chosen because of its reputation for providing quality care for its patient population. The Sisters purchased the facility for $1.

On Dec. 9, 1981, CHRISTUS St. John Hospital treated its first patient. The founding sisters of the hospital, Sister Clare Marie, Sister Frances Therese, and Sister Edwin Berry, worked night and day to build St. John Hospital into the quality health care facility it is today. The hospital opened to serve the needs of the community, merchant marines, workers for the Department of Defense as well as Vietnamese and American shrimpers.

In 1982 CHRISTUS St. John Hospital was one of the first hospitals to have a layman, rather than a member of the Congregation, as administrator. Over the years, CHRISTUS St. John Hospital, located across from Johnson Space Center, has been under contract with NASA for provision of the medication kits for the Space Shuttle and for physiological testing for the space program.

A $9 million expansion that was completed in 1989 debuted the concept of LDRP suites in the Center for New Life, enlarged the emergency department and improved diagnostic imaging capabilities.

On Jan. 23, 1998, the hospital unveiled its new street name and address. Hospital Boulevard was renamed St. John Drive in an official proclamation from the mayor. The hospital’s founding sisters were forever memorialized in the new street address, since the "3" in 18300 was chosen to represent the three sisters.

CHRISTUS St. John Hospital has always been committed to the CHRISTUS Health Mission of extending the healing ministry of Jesus Christ through community involvement and programs. The hospital is responsible for establishing Point of Light Clinic, school-based clinics and Project Gabriel in the Dickinson and Nassau Bay areas. CHRISTUS St. John Hospital also received national attention with the development of its parish nurse program.

CHRISTUS St. John Hospital continues to offer quality acute care health services, has added specialties to serve the community, has actively recruited top physicians to fill the needs of Nassau Bay residents, and remains solid in the mission of mercy envisioned by its founding sisters 20 years ago.

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