Title:  Executive Director, Compliance

Division:  Compliance and Audit Services
Schedule:  Monday - Friday 8:00 a.m. - 5:00 p.m.
Work Location:  Texas Medical Center, Houston, TX
Salary Range:  Commensurate with experience
FLSA Status:  Exempt
Requisition ID:  5815


Responsible for managing the institutional compliance activities for Baylor College of Medicine. Primary oversight of billing compliance and HIPAA privacy programs at the Houston and San Antonio campuses.

Manages institutional compliance activities for the College. Has primary oversight of billing compliance and HIPAA privacy programs. Provides written compliance guidance to departments. Prepares annual report on institutional compliance activities to the BCM Board of Directors. Prepares annual compliance work plans for review and approval of BCM Board of Directors. Develops and updates the BCM Code of Conduct and institutional compliance policies. Directs employees and activities of the Compliance department. Performs other job-related duties as assigned.

Job Duties

  • Oversees the Billing Compliance Program for compliance with billing rules, internal operations, and regulatory requirements. Directs the Senior Compliance Manager on implementation of yearly audit plan. At the direction of the Chief Compliance Officer, provides regular updates to executives, governance sub-committees to review progress on program implementation and corrective action plans.
  • Oversees the compliance training function and directs the development and implementation of annual strategic compliance training plans and programs targeted at current regulatory environment.
  • Serves as the institutional Privacy Officer.  Responsible for oversight and direction of the BCM HIPAA privacy program.
  • Oversees the overall general compliance activities, including, but not limited to Disclosure of Outside Interests, Institutional Hotline and Sanction Checks.  Directs staff to meet institutional compliance standards and goals.  Coordinates with designated functional compliance liaisons and receives regular reports and status updates.
  • Collects regulatory and compliance information and disseminates information to management and staff as required. Oversees the activities of staff in the corporate compliance group.
  • Directs the development and monitoring of Standards of Conduct as it relates to policies, procedures, and regulations.
  • Develops and implements internal monitoring and auditing plans, strategies to assess current state of organizational operations and processes, and to ensure compliance with regulatory standards, legislation, regulation, and internal policy related to accreditation, licensure, billing compliance, privacy and internal operations.
  • Manages and oversees HIPAA Privacy program activities, including investigations, education and monitoring activities.

Job Duties Continue

  • Develops and implements yearly risk assessments and compliance audit activities and integrated strategies for communication of expectations and reporting results are the key functions of this position and include development of Board-level reporting.
  • Develops and communicates the multi-year strategies and objectives of the Compliance Program and report accomplishments.
  • Coordinates with Academics, Research and other departmental leadership in development and implementation of internal compliance program review and risk assessment processes, monitoring and auditing plans, corrective action plans and/or improvement activities.
  • Provides leadership to address regulatory complaints and concerns from internal or external parties, direct and coordinate necessary investigation, and/or corrective action plans with various departments or agencies and communicate progress to leadership.
  • Implements and manages the Corporate Compliance Hotline.  Develops policies and programs that encourage faculty, staff and learners to report concerns without fear of retaliation.
  • Oversees the review, update, and development of all compliance policies and procedures for adoption by the Board of Directors.
  • Develops and implements an annual compliance work plan which is reflective of the significant compliance risks of the organization and the regulatory environment under the direction of the Chief Compliance Officer.
  • At the direction of the Chief Compliance Officer, prepares for and participates in the Clinical Compliance Committee, Executive Compliance Committee and Audit, Compliance and Risk Management Committee of the Board to ensure appropriate and necessary activities/issues are reported.
  • Oversees the implementation and administration of processes designed to maintain compliance with Federal and State laws related to privacy, security, confidentiality, protection of information resources and health care information.
  • Oversees the sanction screening program


  • Willingly cooperates and works collaboratively towards solutions which generally benefit all involved parties; works cooperatively with others to accomplish company objectives; promotes collaboration and partnerships.
  • Maintain channels of communication; effectively provides verbal communication and exhibits good listening skills; provides concise, complete, and professional information to others.
  • Respond to change with a positive attitude and a willingness to learn new ways to accomplish work activities and objectives; understands the potential benefits of short- or long-term employees. Facilitate the development, learning and enhanced performance of other individuals through the use of a variety of coaching techniques.
  • Aware of the industry within which Baylor College of Medicine operates, using knowledge of the organization's position in the marketplace to enhance competitive advantage.
  • Build a logical approach to address problems or opportunities or manage the situation at hand by drawing on own knowledge and experience base and calling on other references and resources as necessary.
  • Demonstrates knowledge of internal client needs, both current and future; addresses complaints, makes realistic commitments, and effectively communicates needs. Accepts full responsibility for self and team, confronts problems quickly and builds commitment to organizational success.
  • Thinks broadly and outside his/her own area or department; sees consequences and potential of all decisions for all stakeholders involved; actions clearly represent commitment and accountability to Baylor College of Medicine patients, doctors, staffs, and community.
  • Develops and uses effective strategies and interpersonal skills to guide others toward the accomplishment of strategic objectives, providing clear direction and priorities, and clarifying roles and responsibilities.
  • Attracts, assesses, develops, and retains a diverse and engaged workforce that drives results; demonstrates timeliness in delivering positive and constructive feedback.

Minimum Qualifications

  • Master’s degree.
  • Ten years of relevant experience.  

Preferred Qualifications

  • Juris Doctorate (JD). 
  • CHC (Certified in Healthcare Compliance) or CHPC (Certified in Healthcare Privacy Compliance).





Baylor College of Medicine is an Equal Opportunity/Affirmative Action/Equal Access Employer.