Director, Compliance Operations @ University of Maryland Medical System

Job Requirements

General Summary

The Director of Compliance Operations provides strategic, operational, and people leadership for enterprise compliance programs and initiatives across UMMS and its Member Organizations. The Director is responsible for translating compliance, regulatory, governance, and operational priorities into effective, scalable processes that support organizational objectives, mitigate risk, and promote a culture of integrity and accountability. The role oversees the strategy, governance, operations, and continuous improvement of assigned compliance programs, including the, Investigations Program, 340B Compliance Program, Drug Diversion Compliance Program, Conflict of Interest (COI) Program.

Responsibilities include program oversight, investigations, auditing and monitoring, risk assessment, corrective action management, education, policy implementation, reporting, and technology enablement. The Director manages, develops, and mentors a team of compliance professionals and serves as a trusted advisor to senior leadership, board members, physicians, and operational leaders on compliance, governance, investigations, and organizational risk matters. The Director also advances the use of Governance, Risk, and Compliance (GRC) platforms, Conflict of Interest (COI) management tools, case management systems, data analytics, automation, and artificial intelligence (AI) to strengthen program effectiveness, reporting, operational efficiency, and decision-making, while partnering with key stakeholders across the health system to drive continuous improvement and compliance excellence.

Principal Responsibilities and Tasks

The following statements describe the general nature and level of work performed and are not an exhaustive list of all duties assigned to this classification.

• Leads the execution and continuous improvement of assigned compliance operations programs in alignment with federal and state requirements, UMMS policies, departmental strategy, and the annual compliance work plan.
• Develops, implements, standardizes, and maintains compliance policies, procedures, standards, operating guidance, workflows, controls, and documentation across UMMS and its Member Organizations.
• Evaluates existing operations and proposed business initiatives for compliance risk and provides practical guidance, recommendations, escalation, and remediation support to business owners and compliance leadership.
• Manages, develops, and mentors assigned team members and program resources, including establishing clear roles and performance expectations; setting priorities; assigning ownership; monitoring workload, quality, and deliverables; providing timely coaching and feedback; supporting professional development and succession planning; fostering collaboration and accountability; recognizing performance; addressing performance or resource concerns; and ensuring timely execution and appropriate escalation.
• Partners with Regional Compliance and Privacy Directors, Privacy, Revenue Cycle Biling and Coding Compliance, Physician Compliance, Internal Audit, Legal, Human Resources, Risk Management, Finance, Supply Chain, Information Technology, and other stakeholders to implement and sustain effective compliance processes.
• Oversees compliance operations projects, including process redesign, system standardization, technology implementation, workflow automation, dashboards, metrics, and reporting that improve program effectiveness and transparency.
• Provides operational oversight and coordination for assigned compliance operations programs and related functions, including risk assessment, sanctions screening, auditing and monitoring activities, policy governance, and compliance education and training as they relate to Compliance Operations programs. Works collaboratively with internal compliance partners to support alignment, implementation, and continuous improvement across compliance operations programs, ensuring that program activities, corrective actions, investigation trends, and identified risks are effectively addressed.
• Prepares and presents clear compliance updates, risk analyses, program metrics, findings, recommendations, and corrective action status to compliance leadership, senior executives, and governance committees.
• Coordinates responses to regulatory, audit, and other external requests within the scope of assigned programs and supports the development and implementation of corrective or preventive actions.
• Manages assigned compliance transitions and special projects associated with organizational restructuring, new or modified programs, service lines, technologies, and enterprise initiatives.
• Monitors program performance, identifies emerging operational and compliance risks, and recommends enhancements to strengthen controls, consistency, scalability, and accountability.
• Represents Compliance on multidisciplinary committees and workgroups and maintains effective relationships with internal and external partners.
• Performs other duties as assigned.

Investigation Program Oversight

• Leads the day-to-day oversight and continuous improvement of the Investigations Program, including hotline intake, triage, case assignment, investigation standards, documentation, quality assurance, escalation, corrective action tracking, and case closure.
• Implements and maintains approved risk-based intake, severity, prioritization, escalation, and investigation standards to promote consistent, timely, objective, and audit-ready handling of compliance concerns across UMMS and its Member Organizations.
• Oversees high-risk and complex compliance investigations and ensures appropriate coordination with Legal, Human Resources, Risk Management, Quality, Security, clinical leadership, Privacy, Revenue Cycle Billing and Coding Compliance, Regional Compliance and Privacy Directors, and other stakeholders.
• Ensures investigators use approved protocols, maintain complete and accurate case records, preserve confidentiality, document findings and conclusions, and communicate status, barriers, and significant risks to appropriate leaders.
• Reviews significant investigation findings and recommends appropriate corrective and preventive actions, referrals, external reporting considerations, and escalation to the Vice President of Compliance Operations or other appropriate leaders.
• Oversees the compliance case management system, including workflows, access, data quality, required fields, reporting, dashboards, aging, closure standards, and continuous improvement opportunities.
• Monitors investigation trends, timeliness, substantiation, recurring issues, corrective actions, and other program metrics to identify systemic risks and inform the annual compliance work plan, education, auditing, and monitoring activities.
• Develops and maintains investigation guidance, templates, training, quality review processes, and team development practices that support consistent execution and professional growth.

Drug Diversion Compliance Program Oversight

• Provides compliance oversight for the enterprise Controlled Substance and Drug Diversion Prevention Program in partnership with Pharmacy, Nursing, Human Resources, Legal, Security, Employee Health, Quality, Information Technology, Member Organization leadership, and other stakeholders.
• Supports enterprise governance and the system-level diversion prevention committee by overseeing compliance-related policies, procedures, standards, program metrics, education, monitoring, escalation, and accountability across Member Organizations.
• Oversees Compliance involvement in suspected drug diversion matters, including intake, risk-based escalation, investigation coordination, case tracking, documentation, corrective action follow-up, and timely communication of significant risks and barriers to leadership.
• Promotes consistent expectations for local diversion committees and diversion response teams, including timely review of concerns, defined ownership, complete case documentation, escalation, remediation, and closure.
• Monitors open cases, case aging, criticality, investigation status, external reporting readiness, recurring control gaps, and remediation activity and provides regular executive and governance reporting.
• Coordinates compliance auditing and monitoring activities related to controlled substance access, storage, documentation, waste, ordering, purchasing, administration, and other high-risk workflows, as appropriate.
• Ensures findings involving potential billing, documentation, patient safety, workforce, or regulatory concerns are referred to the appropriate stakeholders and tracked through resolution.
• Leads continuous improvement of drug diversion investigation processes, reporting, dashboards, education, program tools, and cross-functional accountability to strengthen prevention, detection, response, and remediation.

340B Compliance Program Oversight

• Provides compliance oversight for the enterprise 340B Drug Pricing Program in partnership with Pharmacy, Finance, Legal, Internal Audit, Member Organization leadership, and other operational stakeholders.
• Oversees the compliance governance framework for participating covered entities, including policies, procedures, committee support, defined roles, compliance work plans, education, monitoring, documentation, escalation, and reporting.
• Monitors compliance with program requirements and key risk areas, including covered entity eligibility, patient eligibility, duplicate discounts, diversion prevention, Group Purchasing Organization prohibition requirements, contract pharmacy arrangements, and maintenance of auditable records.
• Reviews self-monitoring results, compliance metrics, audit findings, identified gaps, and management action plans and ensures significant issues are escalated, documented, tracked, and remediated timely.
• Coordinates Compliance participation in internal reviews, external assessments, and regulatory audit readiness activities and advises leaders regarding potential compliance violations, impact assessments, corrective action, and disclosure considerations.
• Promotes consistent enterprise practices by facilitating education, communication, cross-functional collaboration, policy updates, and sharing of effective controls across participating Member Organizations.
• Provides periodic 340B compliance updates, risk trends, program status, and recommendations to compliance leadership, operational executives, and applicable governance committees.

Conflict of Interest Program Oversight

• Provides end-to-end oversight and management of the UMMS COI Program, including annual and ad hoc disclosure processes for applicable workforce members, senior leaders, board members, and other covered populations.
• Establishes program strategy, governance, operating procedures, quality controls, roles, escalation pathways, and performance expectations for the COI Program.
• Oversees the identification of covered populations; disclosure form design and administration; campaign communications; completion monitoring; escalation; and maintenance of complete, accurate program records.
• Ensures consistent review and analysis of disclosures, outside interests, vendor and financial relationships, and other relevant information to identify actual, potential, or perceived conflicts of interest or commitment.
• Approves or recommends appropriate mitigation, including recusals, management plans, monitoring requirements, documentation standards, and escalation to senior leadership or governance committees.
• Oversees the development, issuance, tracking, monitoring, renewal, and closure of COI management plans and promotes accountability for first-line execution and documentation of required controls.
• Serves as a trusted advisor to executives, board members, Member Organization leaders, and operational stakeholders on COI policy interpretation, disclosure obligations, business relationships, contracting matters, and mitigation requirements.
• Oversees COI education, communications, practical guidance, templates, decision-support tools, and other resources for leaders, employees, board members, and compliance partners.
• Ensures timely, accurate reporting of COI program activity, trends, findings, management plans, and recommendations to compliance leadership, executive management, and applicable board or governance committees.
• Leads continuous improvement of COI technology, data integration, risk-based review, automation, reporting, and monitoring capabilities to strengthen program efficiency, consistency, and scalability.
• Coordinates with Legal, Internal Audit, Finance, Supply Chain, Human Resources, and other stakeholders to support effective COI controls and remediation of identified program gaps.

Work Experience

Education and Experience

• Bachelor’s degree in business administration, health care administration, public health, law, nursing, or a related field is required; a master’s degree or doctorate degree in a relevant field is preferred.
• Seven (7) years of progressively responsible experience in health care operations, clinical operations, compliance, legal, internal audit, risk management, or a related field is required, including experience leading complex programs, operational initiatives, and cross-functional teams.
• Healthcare operations or clinical experience within a health system, academic medical center, hospital, physician practice, or other healthcare setting is required.
• Health care compliance experience is preferred.
• Two (2) years of supervisory, team lead, project leadership, or significant program leadership experience is preferred.
• Demonstrated experience supporting or managing conflict of interest, investigations, ethics, policy governance, auditing and monitoring, regulatory compliance, risk management, or other compliance programs is preferred.
• Experience working within a complex, highly regulated health care environment is required.
• Professional certification such as Certified in Healthcare Compliance (CHC), Certified Compliance and Ethics Professional (CCEP), Certified in Healthcare Privacy Compliance (CHPC), Certified Internal Auditor (CIA), Certified Fraud Examiner (CFE), or a comparable credential is preferred. Candidates who do not possess a relevant certification at the time of hire must obtain and maintain an applicable professional certification within two (2) years of employment.

Knowledge, Skills and Abilities

• Strong knowledge of health care compliance principles, program governance, risk assessment, internal controls, investigations, policy management, auditing and monitoring, and corrective action practices.
• Demonstrated knowledge of conflict of interest program administration, disclosure review, conflict analysis, mitigation, recusal, management plans, monitoring, documentation, and governance reporting.
• Ability to translate complex legal, regulatory, policy, and operational requirements into practical guidance, repeatable workflows, and sustainable controls.
• Strong leadership and people-management skills, including the ability to establish priorities, assign ownership, coach staff, manage performance, and drive accountability.
• Excellent judgment and professional discretion when handling confidential, sensitive, or complex matters involving senior leaders, board members, employees, and external partners.
• Advanced analytical, problem-solving, and project-management skills, with the ability to manage multiple priorities and meet deadlines in a complex environment.
• Excellent written, verbal, facilitation, and presentation skills, including the ability to communicate effectively with all levels of the organization.
• Ability to build trusted partnerships, influence without direct authority, manage differing perspectives, and lead multidisciplinary teams toward timely decisions and outcomes.
• Experience using technology, data, dashboards, workflow tools, and automation solutions to improve monitoring, reporting, program administration, operational efficiency, and decision-making.
• Experience with or demonstrated ability to learn Governance, Risk, and Compliance (GRC) platforms, compliance case management systems, and Conflict of Interest (COI) management tools, including workflows, reporting, analytics, user administration, and process improvement.
• Familiarity with artificial intelligence (AI), analytics, automation technologies, and emerging digital solutions, with the ability to identify opportunities to use these tools to improve compliance operations, investigations, monitoring, reporting, and program effectiveness.
• Proficiency in Microsoft Word, Excel, PowerPoint, Outlook, Teams, Microsoft 365 Copilot, Power BI, and other relevant compliance, GRC, analytics, or business applications.

Required Physical and Environmental Demands

• Works primarily in a standard office or remote office environment.
• Requires regular use of standard office equipment, including a computer and telephone.
• Must be able to communicate effectively in person and through virtual platforms.
• Some travel to UMMS locations and off-site meetings may be required.
• Ability to manage multiple priorities and work outside standard business hours when necessary to address urgent compliance matters or meet critical deadlines.
• All requirements are subject to reasonable accommodation in accordance with applicable law.

Benefits

All your information will be kept confidential according to EEO guidelines.

Compensation

• Pay Range: $66.98 - $106.96
• Other Compensation (if applicable):
• Review the 2025-2026 UMMS Benefits Guide