Accreditation and Compliance Specialist

Our centers are dedicated to growing healthy communities by providing access to affordable, high quality, integrated health care for all. The Health Center Accreditation and Compliance Specialist is responsible for reviewing and interpreting regulatory and accreditation requirements, coordinating the collection of necessary data, and submitting documentation to funding agencies and accrediting bodies. This role will ensure the organization maintains its accreditation status, meets all funder-specific criteria and all other regulators of the health centers. The specialist will collaborate with internal teams to gather and organize the information needed for accreditation applications, assessments, and audits. Additionally, the Compliance Specialist functions in an advisory and consultative capacity to foster a culture of integrity and compliance.

Functional Area: Health Center Compliance and Reporting

Estimated Effort: 90 %

Responsibilities, Deliverables, Outcomes and Expectations

• Review and stay up-to-date with regulatory requirements, accreditation standards, and funding agency guidelines to ensure compliance with all relevant rules and regulations.
• Monitor, track and report compliance related activities. Make recommendations for improvements
• Coordinate and gather necessary documentation for accreditation applications, renewals, and audits, ensuring compliance with accrediting bodies (e.g., HRSA, FTCA, CARF)
• Prepare and submit comprehensive accreditation packets and funding reports, ensuring all documentation is complete, accurate, and submitted on time.
• Track and report progress on accreditation activities, including addressing any non-compliance issues and assisting in developing corrective action plans.
• Ensure that changes in accreditation standards or regulatory requirements are communicated to relevant stakeholders and incorporated into organizational processes and practices.
• Preparing for accreditation site visits, including coordinating with relevant departments to provide necessary documentation and arrange staff interviews or reviews.
• Monitor upcoming accreditation deadlines, funder assessments, and required submissions to ensure timely compliance with all applicable timelines.
• Maintain organized records of accreditation and compliance documentation, ensuring that all documents are easily accessible for audits, assessments, or inspections.
• Support training and education for staff on accreditation requirements, compliance standards, and how to maintain eligibility for funding and accreditation.
• Ensure a system of organization of all compliance and accreditation related activities is maintained.
• Participates in internal facility audits to ensure OSHA, HIPAA, HRSA, CARF, and FTCA compliance
• Conduct 340B audits as assigned, assist in monitoring 340B guidance and/or rule changes.
• Provide 340B support to the program manager, includes but not limited to serving as a back-up to process daily claim reviews in the Third-Party Administrator Portal, attend 340B compliance meetings, run reports within the 34B systems and be able to analyze them to ensure compliance.
• Tracks, organizes, and performs follow-up to ensure all recommendations or findings have been addressed from internal or external audits.
• Gather, compile, and organize data, statistics, and other information for reports and presentations, as directed.
• Conduct audits and assessments to evaluate compliance effectiveness
• Analyze compliance data and identify potential risks
• Prepare detailed reports and presentation on compliance findings
• Assist in the development of compliance strategies
• Proficiency in data analysis and reporting tools
• Update OSHA manuals
• Assign and Track required trainings
• Conduct quarterly Code Drills
• Compliance training for new staff
• Ability to work independently and as part of a team
• Excellent written and verbal communication skills
• Quarterly site walk-through
• Regularly review and update policies and procedures to ensure ongoing adheres to accreditation standards
• Scheduling and managing onsite accreditation visits including coordinating with evaluators preparing necessary documentation and facilitating communication with the review team
• Prepare and Coordinate accreditation training to pertinent staff

Functional Area: Other Duties as Assigned

Estimated Effort: 10 %

Responsibilities, Deliverables, Outcomes and Expectations

• Serve on health center and CAC teams and committees as needed.
• Assist with special projects as directed.
• Attends meeting, conferences, and/or trainings as needed.
• Assist in performing all task necessary to achieve the organizations mission, including aligning organization goals with short and long-term qualitative and quantitative measures of success and risks. Any other duties needed to help drive our vision, fulfill our mission, an abide by our organization’s values.