Compliance Department Manager

Job Summary:

Essential Job Functions:

Regulatory Compliance & Program Oversight

• Ensure organization-wide compliance with federal, state, and local regulations, including but not limited to Health Resources and Services Administration (HRSA) Health Center Compliance Program requirements, Health Insurance Portability and Accountability Act (HIPAA) Privacy, 340B, and credentialing/privileging standards.
• Oversee compliance with Centers for Medicare & Medicaid Services (CMS) program requirements, including maintenance and revalidation of provider and site information (e.g., CMS PECOS).
• Ensure accuracy and compliance in regulatory reporting systems (e.g., HRSA Office of Pharmacy Affairs, FTCA EHB portals, etc).
• Develop, implement, and manage the Annual Compliance Plan in collaboration with the CAO.
• 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 by engaging key stakeholders across departments (e.g., HRSA Operational Site Visits, Federal Tort Claims Act (FTCA) reviews, California Department of Health Services audits, accreditation surveys, and others as applicable.)
• Guide departments in audit preparation, documentation, and readiness activities.
• Review audit materials, ensure compliance with requirements, and oversee engagement of key stakeholders to ensure timely follow-up on findings and corrective actions.
• Oversee activities related to:
• HRSA Operational Site Visits (OSV)
• Federal Tort Claims Act (FTCA) reviews
• Department of Health Care Services audits
• Internal agency audits (i.e. HIPAA security, credentialing and privileging, enrollment eligibility and contracts/BAAs)
• Accreditation surveys, including AAAHC, CODA, and other applicable accrediting organizations
• Support activities related to other regulatory audits that involve other agency departments (i.e. clinic services, QI/QA, HR, Fiscal)
• Partner with clinical, operational, fiscal, and administrative departments to:
• Integrate compliance into workflows
• Support audits, licensing, and regulatory submissions
• Implement corrective action plans and process improvements

Risk Management

• Oversee the organization’s risk management program, including:
• HIPAA privacy compliance activities, including breach assessment, incident investigation, and notification requirements.
• Incident reporting concerning claims management and risk mitigation initiatives
• Insurance program management and renewals, in collaboration with Facilities Director
• Federal Tort Claims Act (FTCA) application preparation and submission requirements
• Risk management training and education initiatives
• Ensure compliance and risk issues are appropriately escalated, investigated, documented and resolved through established channels.

Policies, Procedures & Contract Administration Training and Support

• Develop, implement, and maintain organizational policies and procedures.
• Maintain centralized systems for policy management, version control, accessibility, and audit readiness
• Partner with department leaders to develop compliant operational procedures and workflows
• Ensure policies remain current and aligned with regulatory, accreditation and contractual requirements.

Training, Education & Organizational Support

• Develop, coordinate, and deliver compliance, privacy, risk management, and regulatory training programs.
• Provide consultation and guidance to leadership, managers, and staff regarding compliance requirements and best practices.
• Serve as an internal resource on regulatory matters affecting Federally Qualified Health Centers, including HRSA requirements, HIPAA, Medicare, Medicaid/Medi-Cal, and other applicable healthcare regulations.
• Promote organizational awareness of compliance obligations and risk mitigation strategies.
• Support the development and delivery of compliance and risk management training programs.
• Maintain ongoing competence and serve as a resource on issues relating to compliance, including regulations that apply to FQHCs, such as HIPAA, managed care and HRSA regulations.

Data Management, Reporting & Systems

• Oversee compliance systems (e.g., Compliatric) for data collection, validation, tracking, and reporting.
• Develop and maintain data repositories and reporting systems to meet regulatory and accreditation requirements.
• Analyze compliance and risk data and prepare reports, dashboards, and presentations for leadership, Board, and key stakeholders.

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 to ensure accessibility, tracking, and compliance with agreements.

Governance & Committee Support

• Coordinate and/or support internal and Board-level committees (e.g., AHS Compliance, Corporate Compliance, Audit, HIPAA, Safety), including:
• Scheduling and logistics
• Agenda development
• Preparation and distribution of materials
• Documentation of meeting minutes
• Ensure preparation of agendas, meeting materials, reports, dashboards, and meeting minutes.
• Prepare and present compliance, audit, risk management, and regulatory updates to executive leadership and the Board of Directors.
• Evaluate program effectiveness and recommend continuous improvement initiatives. Prepare and present compliance-related reports and updates to executive leadership and the Board of Directors.

Supervisory Responsibilities:

General Agency/AHS Duties:

Minimum Qualifications:

Preferred Qualifications:

Knowledge, Skills, and Abilities: