COMPLIANCE MANAGER

JOB DESCRIPTION
Job Title: Compliance Manager
Department: Operations
FLSA Status: Exempt
 
SUMMARY
 The Compliance Manager serves as the primary liaison for accreditation bodies and regulatory agencies, overseeing audits, inspections, and recertifications. The role is responsible for developing and implementing policies and procedures to maintain licensing and accreditation compliance.   

KEY RESPONSIBILITIES

Conducting internal audits, risk assessments, and investigations of compliance-related incidents, ensuring corrective actions are taken. Maintains organized records of compliance records, regulatory updates, and corrective action plans. Lead compliance training programs for employees, reinforcing ethical guidelines, regulatory standards, and documentation best practices. Collaboration is a critical aspect of the role, working closely with clinical, operations, medical, billing, and quality assurance teams to reduce regulatory risks and uphold culture of compliance. Oversee client care documentation, track grievances and ethical concerns, and implement performance improvement plan based on compliance trends. 

ESSENTIAL FUNCTIONS

• Ensure ongoing compliance with Joint Commission standards, HIPAA, state and federal regulations, 42 CFR part 2, and insurance payer requirements. 
• Serve as the point of contact for all accreditation bodies and regulatory agencies, overseeing audits, inspections, and re-certification processes. 
• Develop and implement policies and procedures to meet licensing and accreditation requirements. 
• Conduct internal audits and risk assessments to identify and resolve compliance issues before external audits occur. 
• Maintain organized records of compliance reports, corrective action plans, and regulatory updates. 
• Investigated and documented compliance-related incidents, reporting findings to leadership and ensuring corrective actions are taken. 
• Develop and lead compliance training programs to all employees, ensuring understanding of Joint Commission standards, ethical guidelines, and documentation best practices. 
• Work closely with clinical, operations, and medical staff to reinforce compliance measures and reduce regulatory risks. 
• Continuously review and update policies and procedures to align with changing regulations and industry’s best practices. 
• Ensure all client care documentation meets regulatory requirements, working with clinical and medical teams to maintain compliance.  
• Oversee and track grievances, incident reports, and ethical concerns, ensuring proper documentation and resolution. 
• Work with leadership to implement performance improvement plans based on compliance trends and findings. 
• Partner with clinical, operations, billing and quality assurance teams to maintain a culture of compliance and accountability. 
• Stay informed of industry changes and communicate updates to leadership and staff 

The job duties listed in this job description may not be inclusive of all requirements of this position.  Other duties may be assigned by your supervisor.

SUPERVISORY RESPONSIBILITIES
 This job has no supervisory responsibilities.

COMPETENCIES
 To perform the job successfully, an individual should demonstrate the following competencies:

Problem Solving - Identifies and resolves problems in a timely manner; gathers and analyzes information skillfully; develops alternative solutions; works well in group problem solving situations; uses reason even when dealing with emotional topics.
Customer Service - Manages difficult or emotional customer situations; responds promptly to customer needs; solicits customer feedback to improve service; responds to requests for service and assistance; meets commitments.
Communications - Expresses ideas and thoughts verbally; expresses ideas and thoughts in written form; exhibits good listening and comprehension; keeps others adequately informed; selects and uses appropriate communication methods.
Teamwork - Balances team and individual responsibilities; exhibits objectivity and openness to others' views; gives and welcomes feedback; contributes to building a positive team spirit; puts success of team above own interests; able to build morale and group commitments to goals and objectives; supports everyone's efforts to succeed.
Ethics - Treats people with respect; keeps commitments; inspires the trust of others; works with integrity and principles; upholds organizational values.
Judgement - Displays willingness to make decisions; exhibits sound and accurate judgment; supports and explains reasoning for decisions; includes appropriate people in decision-making process; makes timely decisions.
 
QUALIFICATIONS

• Preferred bachelor’s degree in healthcare administration, public health or related field. 
• 3-5 years of experience in compliance, accreditation or regulatory or oversight within healthcare, behavioral health, or a related industry. 
• In -depth knowledge of Joint Commission Standards, HIPAA, 42 CFR Part 2, and federal and state healthcare regulations. 
• Experience in leading audits, managing accreditation processes, and conducting internal compliance reviews. 

CERTIFICATIONS (Preferred but not required) 

• Certified in Healthcare compliance (CHC) or Certified Compliance and Ethical Professional (CCEP)
• Certified Professional Healthcare Quality (CPHQ) or other relevant compliance certifications.

 To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

LANGUAGE SKILLS
 Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents.  Ability to respond to common inquiries or complaints from customers.  Ability to communicate effectively through email.  Ability to effectively present information to top management, public groups, and/or boards of directors.

MATHEMATICAL SKILLS
 Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.  Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
 
REASONING ABILITY
 Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

COMPUTER SKILLS
 To perform this job successfully, an individual should have knowledge of Microsoft Office (Word, Excel and Outlook) as well as CRM platforms, specifically Sales Force.

PHYSICAL DEMANDS
 The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this Job, the employee is regularly required to talk or hear.  The employee is frequently required to stand; walk and sit.  The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 10 pounds.  Specific vision abilities required by this job include close vision and distance vision.

WORK ENVIRONMENT
 The work environment characteristics described here are representative of those an employee encounters while