• 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.
• Conduct a comprehensive assessment of UTMB’s current compliance program, organizational structure, capabilities, resources, and areas of risk, and develop a prioritized strategy for strengthening the function.
• Review the compliance organizational structure and build on its current strengths, identifying the talent, resources, systems, and external expertise needed to support an effective enterprise-wide program.
• Establish a cohesive vision and operating model for compliance across UTMB’s clinical, academic, research, and administrative enterprise.

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.

• 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.

• 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.

• 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.

• Serve as a pragmatic strategic advisor who helps leaders identify compliant pathways for advancing UTMB’s clinical, academic, research, and operational priorities.
• Balance regulatory requirements with UTMB’s mission and strategic objectives, providing practical, solution-oriented guidance rather than relying solely on a restrictive or enforcement-based approach.
• Translate complex compliance requirements into clear, actionable guidance that enables end users to understand expectations and secure their commitment to implementation.
• Develop a deep understanding of UTMB’s organizational structure, decision-making processes, and critical stakeholder relationships, building the connections necessary to advance compliance priorities across the enterprise.
• Navigate effectively among clinical, academic, research, administrative, governmental, and external stakeholders, recognizing the distinct compliance considerations and operating needs of each constituency.
• 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.

• 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.
• 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.
• A proven record of leading an enterprise compliance function within a complex academic healthcare environment, including experience strengthening programs, managing organizational change, and addressing significant regulatory and operational risk.
• Prior experience serving as a Chief Compliance Officer or in a comparable senior enterprise compliance leadership role with substantial autonomy and accountability.
• Ability to work cooperatively with multi-disciplinary groups and line managers.
• 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.

• 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.
• 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.