A Brief Overview
This position, under the direction of the Compliance 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, including:
• 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.
For the assigned areas, investigate and document all reported compliance issues, including:
• 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, including:
• 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, including:
• 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, including:
• 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. Additional Responsibilities Amendment for the Compliance Officer responsible for the Conflicts of Interest Program • 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, including: Manages the collection of conflicts of interest data and preparation of conflict management reports for leadership. Assesses and manages disclosures from administrative, clinical, and research staff. Reports and coordinates conflicts of interest management and education. Collaborates 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 that are updated annually. • Provide advice: Advise on procedures, policies, and practices; and • Investigate complaints: 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; and Develop, implement, and evaluate ethical culture and learning & development initiatives. 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. Qualifications: Education Bachelor's Degree preferably in IT, healthcare or related field (Required) Juris Doctor/Law in healthcare administration, compliance or related field (Preferred) or Master's Degree in healthcare administration, compliance or related field (Preferred) Work Experience 2+ years Of experience or post-graduate education in a legal, compliance or related field (Required) Experience with civil rights compliance and training/education/communication highly desired. Knowledge, Skills, & Abilities Ability to work independently, exercise sound judgment and make decisions that comport with applicable laws, regulations and UH policies. (Required proficiency) Excellent interpersonal communication (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. (Required proficiency) Strong working knowledge of Microsoft Office products, including Word, PowerPoint, Access, Access Programming and Excel (Required proficiency)
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