Compliance Manager

Essential Functions

• Manage the day-to-day operation of the organization’s Compliance Program in alignment with HRSA, CMS, OIG, California DHCS, FTCA, and HIPAA requirements.
  • Prepare an annual risk assessment and related compliance workplan, including scheduled monitoring, audits, follow-up activities, and documentation.
  • Identify compliance risks and gaps through audits, reviews, trend analysis, and operational engagement; recommend mitigation strategies to leadership.
  • Maintain confidential reporting channels for compliance concerns and ensure concerns are addressed in accordance with policy and non-retaliation standards.
  • Monitor regulatory changes and support translation of requirements into operational guidance and tools.
  • Prepare and present regular compliance reports and summary dashboards for the Board and/or Board Committees, including key risks, trends, and status of corrective actions.
• Auditing, Monitoring & Spot Checks
  • Conduct or cause to occur internal audits and compliance reviews of identified high-risk areas, including but not limited to the following: Coding and billing compliance, Clinical documentation, UDS reporting and data integrity, Sliding fee discount program compliance, Credentialing and privileging processes.
  • Perform periodic spot checks of departmental practices to assess compliance between formal audits.
  • Document findings, develop corrective action recommendations, and track progress in collaboration with responsible leaders.
  • Maintain audit files, logs, and evidence demonstrating sustained compliance.
• Risks, Incidents & FTCA Related Support
  • Manage incident reporting processes related to compliance, privacy, quality, and patient safety events.
  • Conduct or coordinate root cause analyses and track corrective actions to completion.
  • Serve as a key operational contact for HRSA Operational Site Visits (OSVs) and other regulatory or accreditation reviews.
  • Manage the collection, organization, and internal review of OSV-required documentation, including adherence to HRSA document lists and file-naming conventions.
  • Monitor trends in incidents and compliance concerns and communicate findings to leadership.
  • Serve as the organization’s HIPAA Privacy Officer and/or Security Officer, as assigned.
  • Manage privacy policies, procedures, training materials, and Business Associate Agreements (BAAs).
  • Receive, investigate, and document privacy incidents and potential breaches, including risk assessment, mitigation, notification coordination, and corrective actions.
  • Cook privacy and security safeguards with IT, Operations, and clinical leadership.
  • Maintain documentation and records required for privacy compliance and audits.
• Regulatory Readiness & OSV Support
  • Serve as a key operational contact for HRSA Operational Site Visits (OSVs) and other regulatory or accreditation reviews.
  • Manage the collection, organization, and internal review of OSV-required documentation, including adherence to HRSA document lists and file-naming conventions.
  • Maintain readiness through ongoing documentation review, internal checklists, and mock reviews as needed.
  • Track findings, corrective actions, and follow-up requirements to support sustained compliance.
• Privacy & HIPAA Management
  • Serve as the organization’s HIPAA Privacy Officer and/or Security Officer, as assigned.
  • Manage privacy policies, procedures, training materials, and Business Associate Agreements (BAAs).
  • Receive, investigate, and document privacy incidents and potential breaches, including risk assessment, mitigation, notification coordination, and corrective actions.
  • Cook privacy and security safeguards with IT, Operations, and clinical leadership.
  • Maintain documentation and records required for privacy compliance and audits.
• Internal Reporting Systems and Documentation
  • Administer internal compliance reporting and tracking systems used for intake, investigation, documentation, and resolution of compliance concerns.
  • Ensure consistent documentation standards for incidents, investigations, corrective actions, and audits.
  • Analyze reporting data to identify trends, recurring issues, and compliance priorities.
  • Maintain organized records to support audits, OSVs, and leadership reporting.
• Training & Education
  • Develop and deliver compliance and privacy training content for onboarding, annual training, and targeted education.
  • Provide practical guidance to staff and leaders on regulatory requirements, audit findings, and compliance expectations.
  • Reinforce ethical conduct, accountability, and adherence to organizational policies through education and consultation.
• Policies & Procedures Administration
  • Cook the development, review, revision, and implementation of compliance- and privacy- related policies and procedures.
  • Manage the policy review calendar and ensure timely updates based on regulatory changes.
  • Maintain centralized access to current policies and support departments in operationalizing requirements.
• Collaboration, Authority & Communication
  • Cook with Operations, Finance, Medical, Dental, Behavioral Health, Nursing, Quality, HR, and IT teams to support compliance across service lines.
  • Communicate findings, risks, and recommendations clearly to leadership and stakeholders.
  • Able to work at various health center locations as needed.
  • Able to have reliable transportation to report for shifts.

Minimum Position Qualifications

• Education: Bachelor’s degree required.
• Experience / Training: 5-8 years of healthcare compliance, privacy, and/or regulatory experience.
• Preferred Position Qualifications: Education: Master’s degree or advanced professional degree preferred; Experience / Training: FQHC healthcare experience strongly preferred.
• Licenses / Certifications: CHC, CHPC, CCEP, CPHRM, or similar.