Compliance Officer

Compliance Officer
University Health Services

65241BR

Job Summary

Reporting to the Deputy Executive Director of Harvard University Health Services (HUHS), with a dotted line to the Executive Director, the Compliance Officer administers the Harvard University Health Services Compliance Program by consistently achieving high levels of compliance with all applicable laws and regulations while supporting the vision and mission of the organization. Provides oversight of the HIPAA Security Officer and HIPAA Privacy Officer. Serves as a compliance resource to senior leadership, managers, and employees of HUHS. Collaborates with legal, risk management, and compliance professionals within Harvard Central Administration and, as necessary, individual Schools. Oversees policy management for the organization and HUHS's annual risk assessment initiative. The Compliance Officer's time is divided between the Sports Medicine program (approximately 5%) and other HUHS programs and services (approximately 95%). For both the Sports Medicine program (located at Dillon Fieldhouse) and the other HUHS programs and services, the Compliance Officer will be under the supervision of the Deputy Executive Director.

As a member of the HUHS Executive Committee, the Compliance Officer will provide compliance expertise and guidance to inform organizational strategy, fiscal oversight, and high-level decision-making. The Compliance Officer will work closely with leadership to ensure compliance considerations are factored into day-to-day operations and strategic planning including leading regulatory compliance and oversight of accreditation programs and initiatives. Additionally, the Compliance Officer will monitor key compliance metrics and risks, conduct investigations as needed, and make recommendations to strengthen internal controls and mitigate compliance risks across all areas of the organization.

Compliance Officer:

Participates as a member of the HUHS Executive Committee and HUHS Patient Care Assessment Committee.
Represents HUHS leadership in conversations with staff and external stakeholders. Partners with HUHS leaders to identify, prioritize, and build organizational capabilities through the development and implementation of a compliance learning program.
Develops a compliance plan that is aligned with the strategy/vision of HUHS and addresses any new initiatives.
Develops, initiates, maintains, and revises policies and procedures for the general operation of the Compliance Program to prevent illegal, unethical, or improper conduct. Manages the day-to-day operations of the Program.
Ensures the Compliance Program functions in accordance with all applicable laws, regulations, and accreditation requirements. Periodically reviews standards of conduct to ensure the guidance provided to management and employees is relevant and timely.
Monitors and, as necessary, coordinates compliance activities of other departments to remain abreast of the status of all compliance activities and to identify trends.
Develops an HUHS risk management plan and reports progress to the HUHS Executive Committee. Identifies potential areas of compliance vulnerability and risk; develops and implements corrective action plans for resolution of problematic issues. Provides general guidance on how to avoid or deal with similar situations in the future.

Position Description

Compliance Officer:
Oversees the compliance efforts of the HIPAA Security Officer and HIPAA Privacy Officer as they relate to maintaining current policy and procedure, employee training upon hire and annually, and the reporting of violations and corrective actions.
Coordinates audit activities performed by outside agencies, regulators, and audit functions. Works with other departments to ensure appropriate responses to requests and findings.
Keeps Senior Leadership, the Patient Care Assessment Committee, and the Executive Committee informed regarding compliance activities and changes in regulations impacting HUHS.
Works with the Office of General Counsel (OGC) on regulatory matters as needed; directs compliance issues to appropriate channels for investigation or resolution.
Coordinates compliance learning utilizing multimedia communications tools; educates new staff on the Code of Conduct at new employee orientation.
Promotes employee awareness of ethical practices consistent with the Compliance Program and those required by all applicable laws and regulations.
Develops, coordinates, and administers an HUHS-wide compliance education and training program; assesses the need for additional training and education; and conducts training sessions in various settings.
Ensures the Harvard University Compliance Hotline is publicized and accessible to employees enabling them to report suspected violations and complaints; develops and implements procedures for investigating complaints or concerns relative to compliance issues; ensures uniform handling of such violations/complaints; provides prompt response to detected offenses.
Coordinates with Human Resources, as needed, on physician and employee compliance investigations, findings, and disciplinary matters.
Ensures proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required.
Maintains effective communication with the Board of Registration in Medicine to ensure that HUHS is aware of and complies with any requirements from the Board.
Lead the organization-wide ambulatory accreditation program in accordance with all applicable standards. Provide guidance, information, and advice to managers and administrators, and provides other direction as appropriate. Readies the organization for AAAHC reaccreditation. Responds to survey findings, if needed.
Risk Management:

Leads the organization's risk management review process.
Confers with University Risk Management and Audit Services as needed.
Collaborates with Harvard's Institutional Risk Management Team in the performance and reporting of regular (annual) risk assessments.
Prepares retrospective review of the Annual HUHS Risk Assessment and presents to the Executive Committee. Leads discussion to elicit changes for the coming year based on input from the Executive Committee.
Policy Management:

Acts as policy coordinator with oversight responsibilities for the organization's Policy Management Software.
Responsible for the review and approval of organizational policies of HUHS. Includes the review, revision, and approval process for current policies, the archiving of retired policies, and the writing of new policies in collaboration with the department head or Senior Leader of Service.
Compliance:

Promotes compliance standards across all of HUHS.
Adheres to the expectations and professional responsibilities of the department.
Employs the standards, practices, and procedures of the department.
Completes and complies with HUHS training requirements including HIPAA Privacy and Security.
Reports non-compliance incidents to the appropriate supervisor or manager and may escalate to Senior Leadership and/or Executive Director, as necessary.

Basic Qualifications

Bachelor's degree.
Minimum of 10 years' experience in the healthcare industry with compliance or legal experience, including HIPAA. Certified Healthcare Compliance (CHC) or commitment to obtaining CHC within the first year of employment.

Additional Qualifications and Skills

Work experience in an academic healthcare setting.
Experience with AAAHC or Joint Commission ambulatory healthcare accreditation.
Certification in Healthcare Privacy Compliance (CHPC).
Experience with U.S. Department of Education FERPA provisions.
Experience with healthcare and higher education compliance landscape in Massachusetts.
Expertise in health insurance compliance, including student health insurance plans and ERISA plans.
Experience with PolicyTech or similar policy management platform.

Certificates and Licenses

CHC certification or comparable certification in health care compliance.

Physical Requirements

All Harvard University Health Services (HUHS) staff and staff affiliates are considered Health Care Workers and as a condition of employment must provide documentation of the following:

Letter of good health from your personal health care provider.
TB skin test (within past 3 months) or, if known skin test positive, documentation of previous chest x-ray, information about any past treatment.
Documentation of immunity (positive antibody titers) for Measles, Mumps, Rubella and Varicella.
Proof of appropriate past immunization for Measles, Mumps, Rubella and Varicella.
Hepatitis B vaccine series – required for staff with possible exposure to blood or blood borne pathogens.
A current Flu vaccine (this season) and Covid vaccines to include the Primary series and Bivalent Booster.
The required medical documentation/medical clearances can often be obtained by contacting your Pediatrician, PCP, medical provider. Titers, TB Skin testing can be performed by appointment at Occupational Health facilities.

HUHS continues to place the highest priority on the health, safety and wellbeing of its faculty, staff and students, as well as the wider community. Being up to date with COVID vaccination, annual flu vaccination and other required medical vaccinations and documentation are required as a condition of employment at HUHS. You may claim exemption from the vaccine requirements for medical or religious reasons.

Working Conditions

This position will be in-person.

Additional Information

Harvard University requires a pre-employment reference and background screening.
Harvard University is unable to provide work authorization and/or visa sponsorship.
This position has a 90-day orientation and review period.