Compliance Officer (Hybrid)

Job Description - Compliance Officer (Hybrid) (26000341) A Brief Overview This position, under the direct supervision of the Compliance Supervisor or Director and the Chief Compliance Officer, works closely with key stakeholders to implement elements of the UH Compliance and Ethics Program to ensure compliance with new and existing federal, state, and local laws and regulations affecting University Hospitals Health System. What You Will Do For assigned areas, perform ongoing activities related to the development, implementation, maintenance of and adherence to UH policies and procedures and applicable federal, state, and local laws, rules, and regulations: Chair and coordinate meetings for assigned Compliance Committees. Develop and implement compliance activities for assigned areas with the oversight and direction of the UH Compliance and Ethics Department, including periodic assessment of compliance‑related controls, measurement criteria and monitoring activities. Identify areas of potential compliance risk and take appropriate measures to resolve that risk. Facilitate an environment of open communication allowing employees to report compliance concerns, questions or problems without fear of retaliation. Evaluate the compliance program activities in assigned areas and institute changes/revisions necessary to reflect current laws, regulations and best practices. Evaluate compliance risk in assigned areas to recommend specific compliance activities and initiatives for inclusion on the UH annual compliance work plan. Ensure that each assigned area has internal controls, monitoring and specialized auditing procedures in place for consistent compliance processes. Coordinate and integrate activities and analyses into the assigned area’s quality and risk management program. Assist with the execution of the annual compliance work plan for each assigned entity, supportive and consistent with the UH annual compliance work plan, which outlines each assigned entity’s specific compliance activities and initiatives according to compliance risk areas. Function as the assigned entity’s Compliance Officer or HIPAA Privacy Officer. Investigate and document all reported compliance issues for the assigned areas: Communicate reported issues to the appropriate Director and/or the Chief Compliance Officer. Respond and investigate, in a timely manner, all reported questions and compliance issues, including but not limited to reports received through the UH Compliance Hotline that pertain to the assigned areas. Maintain documentation, including updating the Compliance Databases, of all investigations, corrective actions, and supporting compliance activities. Identify trends in compliance issues and utilize information to design or re‑design systems, policies and procedures and training/education to enhance consistent compliance. Educate personnel about the UH Compliance and Ethics program: Periodically assess assigned area’s overall education needs and identify departments and/or employees who require specialized training to enhance compliance. Assist the Compliance and Ethics Department in the development of education and training materials, including articles for newsletters and other communications relating to compliance program activities. Facilitate training and education to employees relative to the UH Compliance and Ethics Program and each employee’s compliance responsibilities. Assist in the dissemination of compliance information or updates to appropriate individuals within assigned areas. Ensure compliance with HIPAA, HITECH, Ohio law related to confidentiality of health information, and UH policies relating to Protected Health Information: Assist in compliance/privacy investigations, including detailed data analysis and reporting. Investigate compliance issues, analyze findings, and support implementation of appropriate recommendations. Perform compliance training and coaching as requested or indicated. Ensure integration and compliance with UH policies and procedures: Attend and participate in Compliance and Ethics departmental meetings. Participate in relevant system activities and processes. Identify opportunities for enhancing compliance. Participate in periodic compliance strategic planning and effectiveness evaluations. Keep apprised of compliance and regulatory industry developments, including OIG guidance and annual work plans, advisory opinions, CMS updates, significant billing and coding updates, Stark Law and Anti‑Kickback Statute updates. Additional Responsibilities Amendment for the Compliance Officer responsible for the Conflicts of Interest Program: Lead the day‑to‑day functions of the UHHS Conflicts of Interest Program (COI Program), including the development of policies and procedures, the dissemination of education to caregivers, and maintenance of conflict of interest records. Manage the collection of conflicts of interest data and preparation of conflict management reports for leadership. Assess and manage disclosures from administrative, clinical, and research staff. Report and coordinate conflicts of interest management and education. Collaborate with key research departments and leaders to ensure compliance with UHHS COI policies, federal regulations, and applicable sponsor requirements. Amendment for the Compliance Officer responsible for the Civil Rights Compliance Program: Monitor and coordinate civil rights compliance program: ensure UH complies with federal and state regulations, guidelines, and nondiscrimination laws. Develop implementation plans: ensure compliance with federal regulations by developing plans updated annually. Provide advice on procedures, policies, and practices. Investigate complaints that allege discrimination. Amendment for the Compliance Officer responsible for the Compliance & Ethics culture of compliance program: Collaborate with department leadership to develop and execute UH’s culture of compliance strategy. Support caregiver’s understanding of the value of ethical decision‑making and the importance of their role and how it aligns with UH’s values. Develop and implement training plans, tailoring programs to meet the regulatory and organizational goals. Maximize employee engagement with compliance and ethics by providing resources and support. Develop, implement, and evaluate ethical culture and learning & development initiatives. Perform other duties as assigned. Comply with all policies and standards. For specific duties and responsibilities, refer to documentation provided by the department during orientation. Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace. Education Bachelor's Degree preferably in Business Management/Administration, Healthcare Administration or Compliance‑related field (Required) Master's Degree preferably in Business Management/Administration, Healthcare Administration or Compliance‑related field (Preferred) Juris Doctor/Law preferably in Healthcare Administration or Compliance‑related field (Preferred) Work Experience 2+ years experience in compliance related work (compliance programs, patient access, revenue cycle, compliance training & development, regulatory compliance, privacy, investigator, HR Business Partner) or post‑graduate education in legal with a focus in compliance, compliance or related field (Required) Knowledge, Skills, & Abilities Ability to work independently, exercise sound judgment and make decisions that are in compliance with applicable laws, regulations and UH policies. Excellent communication skills (both written and oral). Strong analytic, problem solving and process improvement skills. Demonstrated ability to assume responsibility for activities and projects. Collaborative style that fosters cooperation and involvement. Demonstrated organizational skills with strong attention to detail. Professional and personal integrity and strong value system consistent with the values of UH (Belonging, Integrity, Trust, Service Excellence and Compassion). Strong working knowledge of Microsoft Office products, including Word, PowerPoint, SharePoint and Excel. Demonstrated ability to handle sensitive and confidential information with discretion. Licenses and Certifications Certification in Healthcare Compliance (Preferred) Certified Compliance and Ethics Professional (Preferred) Physical Demands Standing Occasionally Walking Occasionally Sitting Constantly Lifting Rarely up to 20 lbs Carrying Rarely up to 20 lbs Pushing Rarely up to 20 lbs Pulling Rarely up to 20 lbs Climbing Rarely up to 20 lbs Stooping Rarely Kneeling Rarely Crouching Rarely Reaching Rarely Handling Occasionally Grasping Occasionally Feeling Rarely Talking Constantly Hearing Constantly Repetitive Motions Frequently Eye/Hand/Foot Coordination Frequently Travel Requirements 20% Travel to assigned UH Facilities, approximately 1-2 times per week as needed #J-18808-Ljbffr