About the position
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.
Responsibilities
• 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. This includes 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 environment of open communication allowing employees to report compliance concerns, questions or problems without the 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, as appropriate, into 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 (according to the compliance risk areas) each assigned entity’s specific compliance activities and initiatives.
• Function as the assigned entities’ Compliance Officer or HIPAA Privacy Officer.
• For the assigned areas, investigate and document all reported compliance issues
• Communicate reported issues as appropriate 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.
• In conjunction with the Compliance and Ethics Department, identify trends in compliance issues and utilize information to design or re-design systems, policies and procedures and training/education to enhance consistent compliance.
• For the assigned areas, 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.
• For assigned areas, ensure compliance with HIPAA, HITECH, Ohio law relating 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 but not limited to, OIG guidance and annual work plans, advisory opinions, CMS updates, significant billing and coding updates, Stark Law and Anti-Kickback Statute updates.
• Leads 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
• Monitor and coordinate civil rights compliance program: ensure UH complies with federal and state regulations, guidelines, and nondiscrimination laws
• Collaborate with department leadership to develop and execute UH’s culture of compliance strategy
• Performs other duties as assigned.
• Complies 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.
Requirements
• Bachelor's Degree preferably in Business Management/Administration, Healthcare Administration or Compliance-related field (Required)
• 2+ years experience in compliance related work(compliance programs, 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)
• Ability to work independently, exercise sound judgment and make decisions that are in compliance with applicable laws, regulations and UH policies. (Required proficiency)
• Excellent communication skills (both written and oral). (Required proficiency)
• Strong analytic, problem solving and process improvement skills. (Required proficiency)
• Demonstrated ability to assume responsibility for activities and projects (Required proficiency)
• Collaborative style that fosters cooperation and involvement. (Required proficiency)
• Demonstrated organizational skills with strong attention to detail. (Required proficiency)
• Professional and personal integrity and strong value system consistent with the values of UH (Belonging, Integrity, Trust,Service Excellence and Compassion). (Required proficiency)
• Strong working knowledge of Microsoft Office products, including Word, PowerPoint, Sharepoint and Excel (Required proficiency)
• Demonstrated ability to handle sensitive and confidential information with discretion. (Required proficiency)
Nice-to-haves
• 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)
• 4+ years of compliance experience (Preferred)
• Certification in Healthcare Compliance (Preferred)
• Certified Compliance and Ethics Professional (Preferred)