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.
