Summary

Provides professional direction and oversight to the UNM Health Sciences Center Institutional Compliance Program, which incorporates the compliance function for all academic, clinical, and research components of the HSC, as well as the medical faculty practice plan. Serves as the designated Chief Compliance Officer for the Health Sciences Center and is responsible for implementation of the HSC Compliance Program. Reports to the Chancellor of the HSC.

Duties and Responsibilities

1. Develops and ensures implementation of policies and procedures related to HSC standards of conduct and compliance with applicable laws and regulations, particularly those pertaining to healthcare billing and reimbursement, prevention of fraud and abuse, health care privacy, confidentiality, and security, and other identified areas.
2. Leads HSC Compliance Committee consisting of academic, clinical, research, IT and privacy officers.
3. Manages HSC Compliance Hotline and coordinates with UNM Internal Audit, UNM HR and other main campus and HSC departments to ensure issues are appropriately addressed.
4. Manages verification process on employees and vendors against OIG Sanction List and other governmental databases. Performs sanction checks, and provides training to other departments on sanction check process.
5. Responsible for Compliance budget development.
6. Develops and ensures implementation of policies and procedures related to research compliance with government laws and regulations including, but not limited to, research involving humans, animals and biohazardous materials.
7. Coordinates closely with HSC legal counsel, compliance personnel designated by specific HSC units (including the faculty practice plan), and compliance committees established by the HSC or specific HSC units.
8. Under general direction, provides periodic compliance reports to the Executive Compliance Committee, as well as the HSC Board of Directors.
9. Develops, monitors, revises and ensures implementation of the UNM HSC Institutional Compliance Program in response to changes in the law; consults with representatives of HSC components and other constituencies, as necessary to ensure program effectiveness.
10. Develops, coordinates and participates in a multifaceted educational and training program that focus on the elements of the compliance program, and seeks to ensure that all appropriate employees and management are knowledgeable of, and comply with, institutional policies and pertinent federal and state standards.
11. Directs the preparation of short- and long-term strategic and operating plans pertaining to the HSC Compliance Program.
12. Develops an ongoing campaign to heighten awareness of the compliance office function, as well to disseminate information and collect employee feedback.
13. Develops, performs, supervises and arranges appropriate training and education of HSC faculty, staff, and contractors on compliance requirements; monitors and conducts internal reviews to assess compliance with applicable laws and regulations.
14. Monitors and reviews, or oversees the monitoring and review of HSC compliance with applicable laws and regulations.
15. Establishes and manages a reporting system for employees to report concerns and obtain assistance; ensures adequate mechanisms exist for enforcement of compliance requirements and violation discipline.
16. Ensures adequate records are maintained to document compliance efforts and corrective actions.
17. Conducts, supervises, or coordinates investigations of alleged compliance violations; coordinates with HSC officials and managers ensuring remediation of confirmed non-compliance or potential problems.
18. Communicates, or assists in communications with regulatory agencies regarding investigations and alleged violation resolutions.
19. Conducts, or participates in conducting risk assessments for targeted compliance focus by the HSC.
20. Supervises assigned staff and outside consultants, as necessary, in development and implementation of the HSC Compliance Program.
21. Performs miscellaneous job-related duties as assigned.

Minimum Job Requirements

• Bachelor's degree; at least 10 years of experience directly related to the duties and responsibilities specified.
• Completed degree(s) from an accredited institution that are above the minimum education requirement may be substituted for experience on a year for year basis.

Knowledge, Skills and Abilities Required

• Ability to gather data, compile information, and prepare reports.
• Ability to develop and deliver presentations.
• Ability to organize and prioritize work.
• Ability to communicate effectively, both orally and in writing.
• Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
• Records maintenance skills.
• Negotiation and arbitration skills.
• Knowledge of internal and external audit processes and procedures.
• Ability to supervise investigations, analyze information, and draw conclusions.
• Ability to use independent judgment and to manage and impart confidential information.
• Detailed knowledge of laws and regulations affecting business operations of integrated healthcare delivery systems.
• Demonstrated understanding of compliance systems and controls in a healthcare setting.
• Demonstrated ability to develop institutional policies and procedures.
• Supervisory, employee development, and leadership skills.
• Analytical, evaluative, and critical thinking skills.
• Ability to assess training and development needs.

Conditions of Employment

• Employees in this job title are subject to the terms and conditions of an employment contract. Employment contracts are typically subject to review and renewal on an annual basis.
• Employees who provide services or work in patient care or clinical areas are required to be in compliance with the University's influenza vaccination requirement.

Working Conditions and Physical Effort

• No or very limited physical effort required.
• No or very limited exposure to physical risk.
• Work is normally performed in a typical interior/office work environment.

The University of New Mexico provides all training required by OSHA to ensure employee safety.

Revised Date: 10/01/2024