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Summary:

The Vice President and Chief Compliance Officer (VP & CCO) serves as UTMB's senior executive responsible for enterprise-wide compliance, privacy, conflicts of interest, governance, and regulatory risk management. Reporting with independence to executive leadership and compliance governance bodies, the VP & CCO designs, implements, and oversees a comprehensive compliance and ethics program aligned with UT System standards, federal and state requirements, and leading academic medical center best practices.

The VP & CCO acts as a strategic partner to executive leadership, enabling UTMB's clinical, academic, and research missions while ensuring adherence to healthcare laws, regulations, accreditation requirements, and ethical standards. This role champions a culture of integrity, accountability, transparency, and patient safety across a highly complex, integrated academic health system.

Scope: Institution-wide

Responsibilities:

Compliance Program Leadership & Governance 

• Provide executive leadership for UTMB's enterprise compliance, privacy, conflicts of interest, and fraud, waste, and abuse programs.
• Serve as the designated senior compliance officer with authority, independence, and responsibility for program effectiveness, consistent with UT System Regents' Rules and OIG guidance.
• Establish, maintain, and oversee system wide compliance policies, procedures, standards of conduct, and policy governance structures.
• Chair compliance governance committees and function as an independent, objective authority for evaluating and escalating compliance matters.

Regulatory Compliance & Privacy Oversight

• Ensure compliance with applicable federal and state healthcare laws and regulations, including HIPAA, HITECH, Stark Law, Anti Kickback Statute, False Claims Act, and Conditions of Participation.
• Ensure compliance with privacy laws, including but not limited to HIPAA and FERPA, and is accountable for privacy governance, policy framework, workforce training, and PHI incident and breach response.
• Oversee investigations, corrective actions, and remediation activities in response to identified compliance issues and regulatory findings.

Education, Training & Culture of Compliance 

• Design and oversee an enterprise compliance and privacy education strategy, including role based training for workforce members exposed to higher risk activities.
• Ensure ongoing training reflects regulatory changes, industry trends, and internal incident and audit findings.
• Monitor training completion, effectiveness, and continuous improvement of educational methodologies.

Communication & Reporting 

• Oversee confidential and anonymous compliance reporting mechanisms, including the compliance hotline, ensuring non retaliation and appropriate response.
• Promote open communication and transparency across clinical, academic, research, and administrative operations.
• Provide structured, timely reporting on compliance risks, trends, and program effectiveness to executive leadership and governance bodies.

Monitoring, Auditing & Risk Assessment

• Lead enterprise compliance risk assessments and ongoing regulatory change monitoring.
• Oversee risk based compliance monitoring, auditing, and assurance activities.
• Maintain enterprise risk reporting, track remediation activities, and provide actionable insights to leadership.
• Conduct third party and vendor compliance, privacy, and security risk assessments.

Enforcement, Accountability & Corrective Action 

• Partner with Human Resources, Legal, and leadership to ensure consistent enforcement of compliance standards and disciplinary guidelines.
• Ensure timely investigation, documentation, and resolution of compliance incidents, including hotline matters and conflicts of interest disclosures.
• Use lessons learned from audits, investigations, and incidents to enhance program effectiveness and prevent recurrence.

Operational Integration & Strategic Support

• Collaborate with Legal, IT, Human Resources, Health Information Management, and operational leaders to embed compliance requirements into workflows and business processes.
• Partner with clinical, research, and operational stakeholders to ensure compliant EMR configuration, access controls, and data governance.
• Provide compliance due diligence support for mergers, acquisitions, affiliations, divestitures, and strategic initiatives.
• Maintain confidentiality and adhere to UTMB's Code of Conduct and the Health Care Compliance Association Code of Ethics.
• Adheres to internal controls and reporting structure.
• Performs related duties as required.

Knowledge, Skills & Abilities: 

• Must possess strong knowledge of federal and state laws that affect third party reimbursement.
• Must possess strong oral and written communication skills along with the ability to communicate with all levels of the organization.
• Ability to work cooperatively with multi-disciplinary groups and line managers.
• Effective problem-solving skills.
• Ability to manage multiple projects.
• Ability to plan, organize, set and accomplish goals. 
• Ability to analyze/evaluate data and make appropriate recommendations.

Minimum Qualifications:

• Bachelor's degree required in healthcare administration, business administration, public administration, law, nursing, or a related field plus ten (10) years of progressive experience in healthcare compliance, regulatory affairs, privacy, risk management, audit, or a related discipline, within a complex healthcare or academic medical center environment to include five (5) years of executive or senior leadership experience directing enterprise level compliance, ethics, privacy, or risk management functions.
• Demonstrated experience designing, implementing, and overseeing an effective enterprise compliance and ethics program, consistent with federal and state healthcare laws and recognized industry frameworks.
• Thorough working knowledge of applicable healthcare laws and regulations, including HIPAA/HITECH, Stark Law, Anti Kickback Statute, False Claims Act, and Conditions of Participation.
• Demonstrated ability to act with independence and objectivity, advise executive leadership and governing bodies, and manage sensitive regulatory and investigative matters.

Preferred Qualifications:

• Advanced degree preferred, including Juris Doctor (JD), Master of Healthcare Administration (MHA), Master of Business Administration (MBA), Master of Public Health (MPH), or related graduate degree.
• Experience in a public academic medical center, health sciences university, or large multi entity healthcare system.
• Prior experience interacting with or reporting to board level or system level compliance committees.
• Familiarity with UT System policies, public institution governance, or comparable regulatory environments.
• Certified in Healthcare Compliance (CHC) or Certified Compliance & Ethics Professional (CCEP).
• Additional certifications (e.g., CHPC, CIPP/US, CIA, CPA) may be considered based on professional background.
• All certifications must be maintained in good standing through applicable continuing professional education.