Compliance Department Manager

Essential Job Functions

• Regulatory Compliance & Program Oversight
• Ensure organization-wide compliance with federal, state, and local regulations
• Oversee compliance with Centers for Medicare & Medicaid Services (CMS) program requirements
• Develop, implement, and manage the Annual Compliance Plan
• Foster a culture of accountability, ethical conduct, transparency, and continuous improvement in compliance practices
• Audit, Monitoring & Accreditation
• Lead planning, coordination, and execution of internal and external audits
• Guide departments in audit preparation, documentation, and readiness activities
• Oversee activities related to various audits and regulatory submissions
• Support activities related to other regulatory audits involving other agency departments
• Risk Management
• Oversee the organization’s risk management program
• Manage HIPAA privacy compliance activities
• Manage insurance program management and renewals
• Manage incident reporting and risk mitigation initiatives
• Policies, Procedures & Contract Administration
• Develop, implement, and maintain organizational policies and procedures
• Maintain centralized systems for policy management
• Support audits, licensing, and regulatory submissions
• Implement corrective action plans and process improvements
• Data Management, Reporting & Systems
• Oversee compliance systems for data collection, validation, tracking, and reporting
• Develop and maintain data repositories and reporting systems
• Analyze compliance and risk data and prepare reports, dashboards, and presentations
• Licensing, Contracts & Administrative Compliance
• Oversee clinical licensing and certification renewal processes
• Coordinate licensure and certification activities across departments
• Develop and maintain a centralized contract management system
• Governance & Committee Support
• Coordinate and/or support internal and Board-level committees
• Schedule and logistics for committee meetings
• Prepare and distribute meeting materials
• Document meeting minutes
• Supervisory Responsibilities
• Supervise Compliance Department staff
• Provide coaching, mentoring, performance management, and professional development
• Assign and monitor workload priorities and departmental goals
• Ensure confidentiality, professionalism, and accountability in all compliance activities
• Participate as a member of the management team in management team meetings, planning efforts, and organizational initiatives
• General Agency/AHS Duties
• Foster an environment that promotes trust and cooperation among clients and staff
• Enforce clinic policies and procedures, including maintenance of client confidentiality under HIPAA privacy rules
• Participate in organization-wide activities such as AHS general membership meetings, fundraisers, special clinic days, and other events
• Attend AHS staff retreats and Board of Directors meetings, as required
• Participate in agency-wide quality improvement program processes and performance improvement teams

Minimum Qualifications

• Bachelor’s degree in public health, public administration, public policy, business administration, or related field plus three to five years of progressively responsible administrative experience
• Three to five years of progressively responsible experience in healthcare compliance, regulatory affairs, auditing, risk management, or healthcare administration
• Minimum three (3) to five (5) years of progressively responsible experience in healthcare compliance, regulatory affairs, auditing, risk management, or healthcare administration

Preferred Qualifications

• Minimum three (3) to five (5) years of progressively responsible experience in healthcare compliance, regulatory affairs, auditing, risk management, or healthcare administration
• Familiarity with accreditation requirements
• Experience with accreditation and licensing surveys, i.e. Health Resources and Services Administration (HRSA) Operational Site Visit (OSV); The Joint Commission (TJC); Accreditation Association for Ambulatory Health Care (AACHC); Commission on Dental Accreditation (CODA)
• Familiarity with compliance systems, such as Compliatric
• Prior supervisory experience