Director of Compliance

The Director of Compliance is responsible for ensuring the organization adheres to all relevant regulatory requirements, including HIPAA, 42 CFR Part 2, licensing, and accreditation standards. This position will lead the development, implementation, and management of compliance programs and policies to protect the organization’s reputation, legal standing, and patient safety. The Compliance Director will play a key role in overseeing all audits, surveys, and assessments, ensuring the organization maintains the highest standards of quality, safety, and care, and will supervise compliance with legal and regulatory requirements including PHI (Protected Health Information) and EOC (Environment of Care).

Essential Duties And Responsibilities

To perform this job successfully, an individual must be able to perform the following satisfactorily; other duties may be assigned. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Oversee and manage all licensing, accreditation, and certification processes for the organization to ensure ongoing compliance with federal, state, and local regulatory bodies.
• Maintain relationships with accrediting bodies and regulatory agencies to stay current on changes in applicable laws and regulations.
• Prepare and submit required documents for ongoing renewals and updates.
• Ensure compliance with federal, state, and local laws, including HIPAA, 42 CFR Part 2, and other applicable healthcare regulations.
• Stay current on developments related to regulatory changes and implement necessary updates to policies and procedures.
• Lead the organization’s response to regulatory inquiries, audits, and investigations, ensuring full cooperation and accurate documentation.
• Develop and oversee the implementation of quality improvement and safety programs across the organization.
• Ensure compliance with internal and external quality assurance and safety standards.
• Collaborate with leadership to foster a culture of continuous improvement in patient care, safety, and risk management.
• Coordinate and manage internal and external surveys, audits, and inspections related to compliance and accreditation.
• Lead preparation efforts for external audits and ensure the organization is always audit-ready.
• Provide support and guidance to departments to address audit findings and implement corrective actions.
• Oversee the safeguarding of PHI in accordance with HIPAA and 42 CFR Part 2 guidelines.
• Implement and monitor protocols for handling, storing, and transmitting patient information securely.
• Conduct training programs for staff to ensure understanding of privacy and security policies.
• Oversees compliance with Environment of Care standards, including safety, risk management, emergency preparedness, and physical plant management.
• Work with facilities management to ensure the organization meets all safety codes, regulations, and best practices.
• Oversee the facilities performance improvement initiatives
• Develop and implement ongoing compliance training programs for all staff to ensure awareness of regulatory requirements and internal policies.
• Provide regular updates to leadership on compliance trends, regulatory changes, and training needs.
• Conduct RCAs in response to incidents, and present results to executive leadership
• Ensures timely and accurate reporting of any safety, quality, or compliance concerns.
• Coordinate risk management strategies in response to incidents or regulatory deficiencies.
• Serve as a key advisor to executive leadership on all compliance matters.
• Prepare and deliver regular reports to the executive team and board of directors on compliance status, audit results, and regulatory changes.
• Travel to individual sites once a month for compliance walkthroughs and EOC audits.
• Bachelor’s degree in healthcare administration, Business, or a related field or relevant experience.
• At least [3] years of experience in compliance, preferably in a healthcare setting.
• Strong knowledge of HIPAA, 42 CFR Part 2, and other federal, state, and local healthcare regulations.
• Proven experience with accreditation bodies (e.g., The Joint Commission, DCF, AHCA etc.).
• Expertise in the development and implementation of quality assurance, safety, and risk management programs.
• Ability to create and implement policies and procedures
• Familiarity with FARR, Recovery Residence, Hatch and KIPU a plus
  
  

Computer Skills: Proficiency with computers, EMRs and CRMs, current working knowledge of MS Office (Word, Excel, PowerPoint, Adobe) and use of Internet