SUMMARY

The Compliance Officer: (1) Serves as the TMC Health Compliance Officer and, as such, oversees compliance program for all of TMC Health to prevent and detect illegal, unethical, or improper conduct; (2) establishes, implements, manages and monitors an effective compliance program for Tucson Medical Center and TMC Medical Network; (3) oversees and supports an effective compliance program for the other TMC Health subsidiary hospitals; (2) serves as the TMC Health Privacy Officer and, as such, oversees development, implementation, monitoring, and reporting of a privacy program for all of TMC Health designed to support adherence to policies, regulations, and laws relating to the HIPAA Privacy Rule; (3) manages the activities of the Corporate Compliance Department; (4) serves as staff to the TMC Health Board of Trustees’ Audit and Compliance Committee and as Chair of the TMC/TMN  Compliance Committee.

ESSENTIAL FUNCTIONS:

As Compliance Officer, establish, implement, manage, and monitor an effective compliance program.

• Develop a TMC Health Compliance Program to address all program elements recommended by the Department of Health and Human Services Office of the Inspector General (OIG).
• Develop, oversee, and manage an annual compliance work plan for TMC and TMN.
• Oversee and support annual compliance work plans for the other TMC Health subsidiary hospitals.
• Develop policies to address key compliance areas as described by the OIG and to support standards of expected conduct as outlined in the Code of Conduct.
• Develop and direct delivery of education to the organization regarding compliance expectations and the appropriate management of compliance issues and risk areas.
• Conduct annual compliance risk assessments for TMC and TMN.
• Oversee and support annual compliance risk assessments for other TMC Health subsidiary hospitals. 
• Conduct TMC Health compliance program effectiveness assessments.
• Oversee the operation of systems designed to receive internal and external compliance complaints and inquiries (e.g. 24/7 hotline).
• Develop, implement, and oversee the operation of systems designed to detect illegal, unethical, or improper conduct.
• Independently investigate and act on matters related to compliance at TMC and TMN, including the flexibility to design and coordinate internal investigations and any resulting corrective actions with various individuals and departments.
• Oversee and support investigations and actions on matters related to compliance at other TMC Health subsidiary hospitals. 
• Participate with legal counsel in the appropriate reporting of self-discovered violations of program requirements and documenting of compliance investigations.

As Privacy Officer, oversee development, implementation, monitoring, and reporting of a privacy program.

• Develop policies to address key privacy matters as identified by the HIPAA Privacy Rule.
• Develop, implement, and oversee the operation of systems designed to detect violations of the HIPAA Privacy Rule and related organizational policies.

• Oversee the operation and maintenance of systems designed to manage, track, and report privacy incidents i.e. breach tracking logs.

Manage the activities of the Corporate Compliance Department.

• Oversee the TMC Health policy management system, including supervision and oversight of the TMC Health policy intranet site and maintenance of TMC Health policies and processes for creating, reviewing, revising, and updating policies.
• Oversee the operation of systems used to manage receipt, resolution, and reporting of compliance and privacy complaints and inquiries.

• Oversee compliance and privacy investigations, and collaborate with key stakeholders to provide resolution recommendations.

Staff the TMC Health Board of Trustees’ Audit and Compliance Committee and chair the TMC/TMN Compliance Committee.

• Regularly report on the status of the TMC Health compliance program.
• Assist in establishing methods to improve efficiency and quality of services, and reduce TMC Health’s vulnerability to fraud, waste, abuse, and other organizational compliance risks.

Adhere to TMC Health organizational and department-specific safety and confidentiality policies, standards, and values.

Adhere to, and supports team members in exhibiting, the TMC Health values of integrity, community, compassion, and dedication. 

Perform duties as assigned.

MINIMUM QUALIFICATIONS

EDUCATION:  Bachelor’s degree required, preferably in a related field, e.g. law, auditing, business, healthcare administration.

EXPERIENCE:  Six (6) years of industry related experience in healthcare corporate compliance.

LICENSURE OR CERTIFICATION: One (1) or more of the following is required:  Certification from the Compliance Certification Board (CCB) and/or the Health Care Compliance Association (HCCA), CHC (Certified Healthcare Compliance), or comparable certification, or JD.

KNOWLEDGE, SKILLS AND ABILITIES:

• Skill in development of policies and procedures and overseeing implementation.
• Ability to communicate effectively to all levels within and outside TMC Health both orally and in written form and to keep administration informed of activities, needs, and problems.  
• Ability to advise on compliance gaps in standards and objectives and to collaborate with relevant personnel and departments on recommendations or action plans for compliance with company policies or laws and regulations. 
• Ability to perform critical thinking and analysis. 
• Ability to demonstrate effective use of computer software tools to assist in accomplishment of duties. (e.g,. Excel, Word, Outlook, Powerpoint)
• Ability to gather, investigates, research, analyze, and/or study activities affecting hospital-wide or intra/interdepartmental operations. 
• Ability to digest regulatory, industry, and other business guidance, and to communicate and advise necessary actions needed on behalf of TMC Health. 
• Ability to assume responsibilities for carrying out operations in accordance with applicable laws and regulations, securing professional counsel when necessary.
• Strong orientation to deadline and detail.
• Decisiveness and demonstrated exercise of good judgment under pressure.
• Ability to deal with a variety of abstract and concrete variables.
• Ability to manage a diverse and demanding workload.