University Hospitals Compliance Officer in Shaker Heights, Ohio

Compliance Officer

University Hospitals

Shaker Heights, Ohio United States

University Hospitals (UH) is a community-based healthcare system which serves patients at more than 150 locations throughoutNorthern Ohio, including seven wholly owned and four affiliated hospitals.

Committed to advanced care and advanced caring, UH encompasses the regions largest network of primary care physicians, outpatient centers and hospitals. The network also offers specialty care physicians to treat almost every disease and condition, skilled nursing, elder health, rehabilitation and home care services, and occupational health and wellness. University Hospitals is the second largest private sector employer in Northeast Ohio and is within the top five largest private sector employers in the state ofOhio.

Position Summary & Essential Duties: Reporting to the Director and/or Manager of Compliance, the Compliance Officer will be responsible for:

A. For the assigned entities, implement and monitor the organization-wide Compliance and Ethics program and assure integration of the UH Code of Conduct and related policies into all relevant activities, under the direction and oversight of the Director and/or Manager and the Chief Compliance Officer, including:

  1. Enhance compliance and adherence to UH policies and procedures.

  2. 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. Assist in the dissemination of such updates to appropriate individuals within the assigned entities.

  3. Function as the assigned entities’ HIPAA Privacy Officer.

  4. Chair and coordinate meetings of the assigned entities’ Compliance Committee.

  5. Develop and implement assigned entities’ compliance activities 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.

  6. Identify areas of potential compliance risk and take appropriate measures to resolve that risk.

  7. Facilitate environment of open communication allowing employees to report compliance concerns, questions or problems without the fear of retaliation.

  8. Evaluate the assigned entities’ compliance program activities and institutes changes/revisions necessary to reflect current laws, regulations and best practices.

  9. Evaluate compliance risk for each assigned entity to recommend entity-specific compliance activities and initiatives for inclusion on the UH annual compliance work plan.

  10. Participate in joint rounding to promote reporting of concerns and best practices throughout the organization

  11. Ensure that each assigned entity’s operating departments have internal controls, monitoring and specialized auditing procedures in place for consistent compliance processes.

  12. Coordinate and integrate activities and analyses, as appropriate, into assigned entities’ quality and risk management program.

  13. Review each assigned entity’s management responses to UH Internal Audit reports that pertain to compliance-related matters.

A. For the assigned entities, investigate and document all reported compliance issues, including:

  1. Communicate reported issues as appropriate to the Director or Manager of Privacy and Compliance Operations, the Director or Manager of Compliance and/or the Chief Compliance Officer.

  2. 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 entities.

  3. Maintain documentation, including updating the Compliance Database, of all investigations, corrective actions, and supporting compliance activities.

  4. 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.

A. For the assigned entities, educate personnel about the UH Compliance and Ethics program, including:

  1. Periodically assess assigned entities’ overall education needs and identify departments and/or employees who require specialized training to enhance compliance.

  2. 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.

  3. Facilitate training and education to all assigned entities’ employees relative to the UH Compliance and Ethics Program and each employee’s compliance responsibilities.

A. Ensure integration and compliance of individual assigned entities’ activities with UH policies and procedures, including:

  1. Attend and participate in Compliance and Ethics departmental meetings.

  2. Participate in relevant system activities and processes.

3. Identify opportunities for enhancing compliance.

A. Ensure compliance with HIPAA, HITECH, Ohio law relating to confidentiality of health information, and UH policies relating to Protected Health Information, including:

  1. Assist in compliance/privacy investigations, including detailed data analysis and reporting.

  2. Investigate compliance and privacy issues, analyze findings, make and oversee implementation of appropriate recommendations.

  3. Ensure adequate monitoring processes are in place so that access, use and disclosure of protected health information (PHI) comply with legal requirements and UH policies and procedures.

  4. Perform compliance training and coaching as requested or indicated.

  5. Participate in periodic compliance strategic planning and effectiveness evaluations.

A. Fulfill duties as assigned.

*This role may encounter Protected Health Information (PHI) as part of regular responsibilities. UH employees must abide by all requirements to safely and securely maintain 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.


  • Bachelor’s Degree, preferably in IT, healthcare or related field, required.

  • J.D. or Masters in health administration, compliance or related field preferred.

Credentials, Licensure or Certification (i.e. RN, RRT):

  • Certification in Healthcare Compliance preferred, but not required

Experience & Knowledge:

Minimum qualifications include:

  • At least two years of experience or post-graduate education in a legal, compliance or related field required.

  • Ability to work independently, exercise sound judgment and make decisions that comport with applicable laws, regulations and UH policies.

  • Excellent interpersonal communication (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.

Special Skills & Equipment Knowledge:

  • Strong working knowledge of Microsoft Office products, including Word, PowerPoint, Access, Access Programming and Excel required.