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Reporting to Dr. David Lubarsky, Vice Chancellor, Human Health Sciences and Chief Executive Officer, UC Davis Health, the Chief Compliance & Privacy Officer is responsible for the direction and leadership of the Compliance & Privacy Program for UC Davis Health, including regulatory, billing and coding, and research compliance and federal (HIPAA) and state (COMIA and IPA) privacy compliance. The position also has a dotted line reporting to the Senior Vice President and Chief Compliance and Audit Officer in the University of California’s Office of the President.
Major Duties/Accountabilities
The Chief Compliance & Privacy Officer directs and monitors the implementation and operation of the compliance program.
- Reports on a regular basis to the UC Davis Health compliance governing board on the status of all current compliance programs. Works closely with the compliance governing board to develop and implement new programs that promote UC Davis Health's commitment to quality of services and reduces vulnerability to fraud, waste and abuse.
- Serves as the executive liaison to the campus on all matters relating to UC Davis Health Compliance & Privacy. Participates in executive-level campus compliance and privacy committees. Serve as a key member of campus committees focused on institutional compliance risks.
- Works closely with the University of California Compliance Office and participates as a member of the Health Sciences Compliance Committee, and other UC committees.
- Serves as the UC Davis Privacy Officer, responsible for the health system's state-of-the art Al-based patient privacy monitoring system (Protenus) and required federal and state reporting.
- Provides oversight aimed at ensuring that UC Davis Health complies with applicable federal, state, and local statutes and regulations. Works closely with in-house and retained legal counsel on larger compliance and privacy matters.
- Develops, coordinates, and participates in a multifaceted educational and training program that focuses on the elements of the compliance program, and seeks to ensure that faculty, students, staff, and management are knowledgeable of and comply with pertinent federal and state standards.
- Coordinates personnel and professional services issues with the Medical Staff and Human Resources, as appropriate.
- Collaborates with UCD Audit and Advisory Services in coordinating internal compliance reviews and monitoring activities; including annual or periodic reviews of departments.
- Independently investigates and acts on matters related to compliance and privacy, including the flexibility to design, direct and coordinate internal investigations (e.g., responding to suspected violations), coordinating when necessary with other offices such as the UC Davis Compliance & Policy office, Research Compliance within the Office of Research, Employee & Labor Relations and Academic Personnel and provides input for any resulting corrective action.
- Supervises professional and support staff in the administration of the Compliance and Privacy Program. Prepares and monitors the department budget with guidance and approval from the compliance governing board.
- Develops policies and programs that educates employees and students and encourages workforce members to report suspected fraud, privacy breaches and other improprieties without fear of retaliation.
- Prepares and carries out an annual work plan for the UC Compliance Office that includes identifying compliance risks for UC Davis Health and working collaboratively with departments to develop work plans. Performs routine auditing and monitoring to assess overall compliance in the risk areas identified in the annual work plan.
The Chief Compliance & Privacy Officer oversees the Privacy Program to assure compliance with current HITECH/HIPAA regulations, including identification, implementation and maintenance of UC Davis Health information privacy policies and procedures. The Privacy Officer ensures:
- Effective risk assessments and monitoring activities are conducted.
- Maintenance of appropriate forms and information notices and materials reflecting current organization and legal requirements.
- Delivery of privacy training and orientation to all appropriate University personnel.
- A mechanism to track access to protected health information within the purview of the University of California System as required by law and to allow qualified individuals to review or receive a report on such activity.
- Cooperation with the Health System HIM personnel and Security Officer in overseeing patient rights to inspect, amend, and restrict access to protected health information when appropriate.
- A process for receiving, documenting, tracking, investigating, and acting on all complaints concerning UC Davis Health privacy policies and procedures in coordination and collaboration with other similar functions and, when necessary, legal counsel.
- Compliance with privacy practices and consistent application of sanctions for failure to comply with privacy policies for all individuals in the UCDH workforce, extended workforce, and for all business associates, in cooperation with Human Resources, the Information Security Officer, administration, and legal counsel as applicable.
- Coordinate with the School of Medicine Clinical Research for the training of investigators, research coordinators and staff on privacy issues for clinical research. Assists all areas of research in development of QA activities for privacy in clinical research and receive and review results of QA audits. Serves as key liaison to UCD's Independent Review Boards (IRBs) and related committees.
- Responsible for all compliance office employees with management of their activities and the efficiency and effectiveness of the department.
- Performs annual employee performance evaluations of direct reports and, through subordinates, ensures that Compliance Department employees receive annual written performance evaluations. Ensures that proper follow-up is maintained when an employee's job performance warrants remedial action.
- Defines the qualifications and performance expectations for all staff positions. Tracks qualifications and competencies of current staff against projected staffing and competency needs to identify any deficiencies and improve professional skills. Directly supervises, evaluates, and contributes to the professional development of staff within assigned functions, including coaching employees and identifying training and networking opportunities.
- Identifies, analyzes, and assists in implementation of methods for increased intradepartmental/program productivity by making tasks within a program and across programs more efficient and responsive.
- Coordinates activities between departments/programs to avoid duplication, increase efficiency and provide higher levels of service where appropriate.
Minimum Qualifications
- Bachelor’s degree in clinical or related area, and/or equivalent combination of experience /training.
- Extensive compliance experience in healthcare, preferably in an academic health science setting.
- Demonstrated understanding of all elements of compliance in relation to practice plan management and healthcare delivery, including strategy, business planning, operations, and finance.
- Advanced knowledge of federal and state health services regulations, including Medicare, Medicaid, and third-party payers, as well as federal and state privacy rules and regulations.
- Extensive knowledge of state and federal privacy regulations including CMIA, IPA and HIPAA/HITECH.
- Expertise in all aspects of assigned functions, including development and management of compliance plans, reporting systems, and controls.
- Knowledge of the issues and challenges facing healthcare entities with a full understanding of, and ability to effectively respond to changes in healthcare and research practices, legal/regulatory changes, and technological trends.
- Demonstrated high standards of leadership, professionalism, performance, quality, credibility, and integrity. Exhibits judgment and business acumen necessary to effectively advocate for the compliance program.
- Exhibits judgment and business acumen necessary to effectively advocate for the corporate compliance program.
Preferred Qualifications
- Certification in Healthcare Compliance (CHC) and Certification in Privacy, Privacy and Security (CHPS) is preferred.
- Master’s (or other advanced degree) in related field or discipline.
Benefits
Outstanding benefits and perks are among the many rewards of working for the University of California. UC Davis offers a full range of benefits, resources and programs to help you bring your best self to work, as well as to help you and your family achieve your health, wellness, financial and career goals. Learn more about the benefits below and eligibility rules by visiting either our handy Benefits Summary for UC Davis Health Employees or Benefits Summary for UC Davis Employees and our Benefits Page.
