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JOB SUMMARY:

The position reports to the UMC governing body, known as the Board of Managers; the Board is a group of community leaders, appointed by the County of Lubbock, and who represent the diverse constituents of Lubbock County. In addition to this direct reporting structure, the Officer also reports – in an administrative capacity – to the CFO of UMC Health System. The position is responsible for leadership and guidance in establishing and implementing an effective compliance program that addresses regulatory requirements governing a major academic medical center. The position is responsible for coordinating internal compliance review and compliance monitoring activities to ensure that UMC is in compliance with applicable statutory, regulatory and other standards, and that effective policies and procedures are in place. The employee works with UMC leadership team to conduct periodic risk assessments to identify potential areas of compliance vulnerability and risk, and acts as an advisor to senior leadership with respect to all compliance matters. The employee oversees the administrative conflict of interest management process.


REPORTS TO: Chief Financial Officer


JOB SPECIFIC RESPONSIBILITIES:

I. Development and implementation of the compliance program
• Develop and implement the compliance program, to include conducting investigations, risk analysis, internal audits, and reporting; scope to include but not limited to Medicare, Medicaid, Office of Inspector General and associated regulatory activities
•Analyze all available resources to perform a compliance risk assessment, and develop annual work plans.

The Compliance Work Plan includes:
o Human Subjects Research Compliance
o Clinical Trials Billing Compliance
o HIPAA Privacy and IT Security
o Federal Grants Compliance (effort reporting, cost transfers, other support, allow ability and allocability of charges to federal grants)
o Conflict of Interest
o IACUC regulatory and accreditation requirements - Institutional Biosafety regulatory
requirements - Select Agent Program regulatory requirement

II. Operations and monitoring of the compliance program
• Carry out complaint investigations related to compliance issues and concerns
• Monitor and report results of the compliance audit plans, timely and completely
• Function independently and objectively in reviewing and evaluating compliance issues
• Serve as the Privacy Officer for UMC:
o Conduct proactive reviews related to HIPAA Privacy and Security; include HIPAA compliance within the scope of human subject research compliance reviews
o When issues of disclosure or breach are identified, conduct a full risk assessment with sanctions imposed, as appropriate under the HIPAA Breach Policy
o Ensure disclosures are included in annual disclosure accounting and any required
notifications to individuals or the Office of Civil Rights occur
• Investigate and report findings working with Internal Audit and Legal Affairs and other functions as appropriate to understand and resolve any compliance issues identified
• Respond promptly to detected compliance issues from compliance audits and monitoring
• Partner with senior leadership to develop internal controls and mitigation strategies for areas of improvement identified in compliance reviews, audit plans and monitoring results
• Oversee and manage the RASMAS recall alert system for UMC

III. Oversight and outcomes of organizational compliance
• Oversee a comprehensive compliance program that addresses the regulatory requirements for the conduct of research, other highly regulated risk areas, defined institutional risks, as well as directives or for cause reviews from senior leadership
• Ensure business operations are in accordance with applicable federal, state and local laws
• Ensure the Board, leadership and employees are in compliance with the rules of regulatory agencies, that organizational compliance policies and procedures are being followed, and that behavior in the organization meets UMC’s Code of Conduct
• Provide measurable results that document the effectiveness of the compliance program
• Serve as primary on site facilitator/liaison when on-site federal or state audits of risk take place, communicating with federal or state audit teams on behalf of the institution
• Manage the UMC hotline for anonymous reporting of compliance issues, and protection of whistleblowers
• Act on matters of reported or suspected non- compliance; implement internal investigations and resulting corrective action; coordinate with Legal Counsel for those investigations to be conducted under attorney-client privilege
• Provide advisory services and oversight related to required regulatory research review committees: Institutional Review Boards (IRBs), and Institutional Biosafety Committee (IBC). Periodically review these committees to ensure compliance with regulations. Make recommendations to these committees regarding any compliance aspects of research involving animal or human subjects and/or use of recombinant DNA and other biohazards.

IV. Leadership and communication
• Provide guidance to the Board and senior leadership regarding compliance matters, specifically any significant findings from compliance reviews and monitoring results as well as any federal reports indicating a need for broader institutional remedial action
• Research and respond to questions and complaints raised to the Compliance Office by employees, leadership, or others
• Provide leadership and oversight for the UMC compliance program at all levels; chair the Compliance Committee
• Encourage all staff to report suspected fraud and misconduct without fear of retaliation
• And perform all other duties as assigned, to support the culture and operations of UMC.


EDUCATION AND EXPERIENCE:

• Bachelor’s degree required in related field ; Masters preferred.
• Five years healthcare compliance experience. Preferred experience also in an academic, research or other comparable environment. Specialized training/experience preferred in one or more of the following: human subjects research, HIPAA/HITECH, clinical trials, billing compliance, lab safety and biosafety, and/or environmental health and safety.

Certified in Healthcare Compliance (CHC) preferred.

SKILLS AND ABILITIES:

• Thorough knowledge of healthcare compliance and the regulatory requirements impacting a
medical center.
• A track record of success in daily and strategic oversight of compliance, with an understanding of the complexities and operational processes associated with a healthcare system.
• Demonstrated experience managing a comprehensive compliance program, including developing and implementing appropriate training and internal monitoring activities.
• Demonstrated credibility and effectiveness in interacting with stakeholders including senior leadership, governing entities, internal customers, and external regulators. Must be able to describe your leadership and teamwork skills as they support the culture of UMC.
• Excellent oral and written communication skills.


INTERACTION WITH OTHER DEPARTMENTS AND OTHER RELATIONSHIPS:

This position interacts extensively with hospital personnel. Other relationships include TTUHSC personnel, physicians, patients and their families, and many other external customers.


PHYSICAL CAPABILITIES:

Occasional lifting boxes up to 20 lbs. will be required; however it is possible that arrangements for help can be made if applicant's skills outweigh a lifting disability. The employee will frequently exert a small amount of force to lift, carry, push, pull and move objects. The employee will sit at a computer and keyboard for long hours.


ENVIRONMENTAL/WORKING CONDITIONS:

The position is subject to inside environmental conditions and some outside activities; protection from weather conditions, not necessarily from temperature changes.


DIRECT REPORTS:
Program Director, Clinical Research
Assistant Director, Compliance
Senior Compliance Specialist
Research Compliance Specialist

UMC Health System provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment on the basis of race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

*Request for accommodations in the hire process should be directed to UMC Human Resources.​*