Compliance Officer

The Compliance Officer reports directly to the Compliance Officer Supervisor and ensures that the organization’s services are conducted in compliance with the regulatory requirements of payers and licensors, the requirements of program contracts, and applicable accreditation standards. The Compliance Officer reviews employee works across all Passages to Recovery lines of service to ensure quality and compliance in charts, and documentation; develops policies; and responds to policy violations. The Compliance Officer works with the Executive Management Team to incorporate compliance into performance expectations; takes proactive measures to stay informed about important changes in applicable regulations and guidance; and works with the Executive Management Team to communicate and implement those changes. In the rapidly changing regulatory environments of healthcare, human services and corrections, the Compliance Officer protects the organization from poor audit performance and financial exposure and safeguards its professional reputation.

Essential Duties and Responsibilities

Develop and implement an internal audit program to ensure that the organization operates in accordance with all contractual, licensing, payer and accreditation requirements and guidance:

• Determine compliance metrics and establish a tracking system.
• Develop and conduct regular internal contractual, licensing and payer audits in all departments within an established timeframe.
• Deliver prompt written and verbal feedback to Executive team and department directors following every internal audit; follow up on departmental plans to correct audit deficiencies and summarize findings in monthly and quarterly progress reports to Executive Leadership Team
• Conduct monthly meetings with Departmental Directors and supervisors to review internal audit performance, evaluate training needs, communicate changes and updates to requirements, and discuss barriers to compliance
• Provide regular training and development to supervisors and staff on compliance requirements and procedures; answer individual questions as they arise.
• Stay informed about regulatory changes and emerging rules by monitoring regulatory agency websites, following regulatory agencies on social media, subscribing to relevant blogs and newsletters, engaging in educational opportunities, etc.
• Develop, and assist with dissemination of, new policies, procedures and protocols as needed.

Create a culture of excellence in compliance:

• With the Department Directors, create and distribute regular agency-wide memos, newsletters, etc. that explain why compliance matters, acknowledge outstanding staff performance, communicate areas of concern, and convey regulatory and contractual changes
• With the Chief Program Officer and Department Directors, develop an annual compliance training schedule.
• Work with Department Directors to develop processes, procedures and incentives that address barriers to compliance.

Facilitate external audits and relationships:

• Maintain all files and documentation necessary for contract and licensing audits.
• Prepare data for outside payer audits.
• Be on site for external audits and available to auditors.
• Provide guidance for, and assist in the completion of, corrective action plans as needed.
• Follow up with Chief Programming Officer and Facility Directors on corrective action plans; integrate areas of improvement into regular discussions and trainings with supervisors and staff
• Act as project manager for the design and execution of accreditation documentation systems and policy development, assume responsibility for maintaining those system once established, and act as liaison with accreditation boards and associations.

Additional Duties may be assigned as required.

Required Competencies and Abilities

• Content knowledge: must be familiar with and fluent in all regulatory and contractual compliance for which the organization is responsible or have sufficient prior experience that requirements can be quickly learned; must have strong knowledge of protocols and best practices in the organization’s fields of service.
• Problem solving: Must have strong analytical and creative skills; able to accurately interpret complex documents and policies; able to draft a simple structured solution in the face of unclear or obscure regulatory policies.
• Communication skills: Must have excellent written and verbal communication skills so that staff at every level of the organization receives vital understandable compliance information at the right time.
• Detail oriented: Must have genuine interest in, enthusiasm for and focus on the minutiae of documentation and records.
• Time management and organizational skills: Must be able to review and effectively process quantities of data and meet deadlines.
• Conflict management skills: Must have ability to handle dissension in an objective and impartial manner and have confidence and resilience when dealing with external regulators.
• Training and presentation skills: Must be able to educate staff on compliance requirements, identifying or developing training modules and tools in collaboration with the Training Specialist
• Ethics and confidentiality: Must have integrity and maintain confidentiality of sensitive client and operational information during and after employment with the organization.

Required Education and Experience:

• Master’s Degree or above from an accredited college preferred, with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management, accounting, law, social administration, human services administration, or organizational leadership; with five years of experience in a human services agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning, or

a bachelor’s degree in a related field with seven years of related experience

• A thorough understanding of corrections and drug and alcohol treatment concepts, practices and procedures is required.

Certificates, Licenses, Registrations:

• Must have, or meet the requirements to obtain, current ACT 33 & 34 Clearances.
• Must be able to obtain Allegheny County Jail Clearances and additional clearances as required.
• PCB approved certification or licensure preferred. (CADC, CAADC, LPC, CCS, LPC, LSW, ETC.)
• Must have a valid driver’s license and full-time use of an insured vehicle.
• Must annually complete all training hours required by Passages to Recovery licenses, contracts, and accreditations. 

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