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Healthcare Compliance Program Description


Rutgers is committed to providing high quality healthcare, teaching, and research to achieve our institutional mission of advancing health worldwide. We can meet these responsibilities only when each member of the clinical enterprise understands and adheres to the Rutgers University Code of Conduct and its high standards. Rutgers University Healthcare Compliance program is intended to provide guidance and oversight to clinical enterprise programs as a means to ensure that ethical, compliant behavior is a standard and integral part of all Rutgers University clinical operations.


The program strives to:

  • promote a culture of compliance throughout the organization by aligning compliance activities with organizational strategies;
  • maintain a culture promoting the prevention, detection and resolution of potential violations of applicable laws and regulations, professional standards of practice, other applicable standards, and Rutgers University policies; and
  • empower employees, agents, medical staff members, and students to individually and collectively act in accordance with university compliance policies, applicable governmental and professional standards and requirements; to act and conduct operations with the highest level of integrity and ethics.


The strengths of the Rutgers University Healthcare Compliance Program are rooted in the seven elements of an effective compliance program as set forth under the U.S. Federal Sentencing Guidelines.

Senior Vice President for University Ethics, and Compliance exercises effective oversight of the Rutgers University Compliance program, and has direct reporting authority to both the Audit Committee (need official name) and to the University President.

The RBHS Corporate Compliance Committee comprised of senior leadership of RBHS who meet quarterly, and is charged with the responsibility of operating and monitoring the RBHS compliance program.

Compliance Officers are charged with promoting and implementing compliance and practice standards at the unit level, and also provides guidance to the Rutgers community. In addition, our compliance officers play an integral role in

  • developing and implementing regular and effective education and training programs;
  • keeping units current on relevant law, policies, and compliance matters;
  • identifying potential compliance risks within each unit;
  • responding appropriately to detected offenses; and
  • assisting in the development and implementation of corrective action plans.


Compliance Auditors conduct routine reviews monitoring the adherence to billing, coding, documentation guidelines, and applicable laws. Auditors assist in the reduction of potential risk to the University.

University-Wide Compliance Hotline provides a mechanism for members of the Rutgers Community, including the general public, to report compliance matters anonymously or to receive guidance on possible compliance issues. A complaint can be filed directly with our office or by phone 1-800-215-9664.

The Investigations Team is charged with investigating billing and coding issues, conflicts of interest, falsification of documents, fraud, patient confidentiality breaches, and violations of law or policy, not only at RBHS, but also as part of our Institutional Compliance Program.

Policies and Procedures have been established to promote the Rutgers commitment to compliance and to address specific areas of potential violations of law and to enforce disciplinary standards. They can be accessed via the university’s policy library.