Compliance Program Manager

JOB SUMMARY:

The Compliance Program Manager (CPM) provides leadership and support in the Compliance Department, including accreditation efforts for the organization. The CPM coordinates and monitors compliance activities for all departments of the health center to ensure the health center’s contractual, legal, and programmatic requirements are met, including accreditation processes, with particular emphasis on program areas such as dental residency program and accreditation processes (including Accreditation Association for Ambulatory Health Care (AAAHC) and Commission on Dental Accreditation (CODA). This involves working with key management staff to review written policies and procedures, review contracts, conduct internal audits and monitoring, provide staff training/education, develop corrective action plans, and investigate possible violations. The CPM oversees the accreditation processes, and supports efforts that ensures the Compliance Program is a process-oriented comprehensive program that conforms to applicable laws and regulations and fosters a culture of compliance throughout the organization. The CPM reports directly to the Chief Administrative Officer/Compliance Officer and works collaboratively with leadership across the organization.

ESSENTIAL JOB FUNCTIONS:

COMPLIANCE & ACCREDITATION:

1. Responsible for ensuring compliance with local, state, and federal rules, regulations, and contracts that impact clinic operations, including accreditation processes such as: Health Resources and Services Administration (HRSA); Accreditation Association for Ambulatory Health Care (AAAHC); Commission on Dental Accreditation (CODA); credentialing/privileging; Health Insurance Portability and Accountability Act (HIPAA) Privacy; and Incident Reporting) including coordination of audits and the development and implementation of corrective action plans, and other accreditations as needed.

a. Accreditation coordination includes, but not limited to:

i. Tracks the timeline for all accreditation required reports;

ii. Develops drafts of needed policies and reports in coordination with the affiliated residency/ training program or other required needs;

iii. Works with accreditation institution to develop schedules for site visit reviewers; and

iv. Organizes documentation needed for a successful site visits.

2. Works with Chief Administration Officer (CAO) on activities related to the auditing and monitoring program including but not limited to, (i) providing guidance related to preparing work for the audits, (ii) reviewing the audit documentation, (iii) providing guidance on preparing reports and

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analysis, (iv) ensuring necessary follow-up is performed, and (v) ensuring that appropriate audit documentation is maintained.

3. Collaborates closely with other departments to develop, revise, and ensure maintenance of AHS policies and procedures for the general operation of the AHS Compliance Program, including but not limited to the Dental Residency Program and its related activities to prevent illegal, unethical, or improper conduct.

4. Working under the direction of the CAO, and key clinical staff leads including the Director of Dental Education and Chief Dental Officer, manages the AHS Annual Compliance plan to help ensure teaching, training, and residency programs, including the dental residency program, policy and procedures follow organization-wide adherence to state and local laws, regulations, and guidelines, organizational standards, accreditation bodies, and AHS’s policies and procedures.

5. Maintains a data repository and reporting system that meets regulatory requirements for Compliance Programs and activities by federal and accreditation organizations (i.e. HRSA, AAAHC, CODA, etc.)

6. Supports, participates and takes leadership on HRSA’s OSV program components as needed. 7. Monitor regulatory communications from CMS, DHCS, CPCA, Dental Board of California, and other regulatory agencies.

8. Collaborates with other departments to direct compliance issues to appropriate existing channels for investigation and resolution.

9. Analyze and present data related to compliance and prepare reports for leadership, board, and other stakeholders.

10. Assist in submitting required programmatic reports for teaching, training and residency programs, including the HRSA Teaching Health Center program, to ensure residents’ clinical experiences and standards of accreditation, such as CODA, are being followed.

11. Helps monitor the progress of residents and as needed, trainees, fellows, and students, to ensure graduation requirements required by accreditation agencies, such as CODA, are met.

12. Perform other compliance related duties as assigned.

TRAINING & SUPPORT:

1. Work closely with staff on compliance activities, such as trainings, workflows, and development of policies and procedures. 2. Coordinate and administer compliance training and education with a focus on the elements of the AHS Compliance Program, ensuring that applicable staff, supervising faculty, and residents are knowledgeable of and comply with AHS policies and procedures and applicable federal and state standards.

3. Maintain ongoing competence and serve as a resource on issues relating to compliance, including regulations that apply to FQHCs, such as HIPAA, managed care, AAAHC, CODA, and HRSA regulations.

4. Supports departmental leads in preparing for and coordinating audits, site visits, or inspections by external regulatory bodies, including HRSA, AAAHC, and CODA.

GENERAL AGENCY/AHS DUTIES:

1. Fosters an environment that promotes trust and cooperation among clients and staff.

2. Enforces clinic policies and procedures, including maintenance of client confidentiality under HIPAA privacy rules, to ensure that the principles of AHS are implemented.

3. Plays an active role in planning organization-wide activities such as AHS general membership meetings, fundraisers, special clinic days, and other events.

4. Participates in general membership meetings, fundraisers, and other public events, as required.

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5. Participates in outreach activities, agency advocacy, and serves on ad hoc committees, as requested.

6. Attends AHS staff retreats and Board of Directors meetings, as required.

7. Participates in agency-wide quality improvement program processes and performance improvement teams to ensure excellence in the quality of services provided across the agency.

MINIMUM QUALIFICATIONS:

1. Bachelor’s degree plus three to five years of progressively responsible administrative experience, or any equivalent combination of education and experience.

KNOWLEDGE, SKILLS, AND ABILITIES:

1. Proficiency with Microsoft Office applications and adaptability to working with computers and software applications.

2. Ability to work collaboratively with other AHS supervisors and managers with a focus on customer service and quality of care, exemplifying the core values and mission of the organization.

3. Ability to work collaboratively to achieve common goals and communicate within different levels of the organization. 4. Ability to exercise sound independent judgment and to effectively manage time and resources. 5. Ability to read, understand, and present contracts and government regulations.

6. Demonstrated leadership skills with the ability to train and guide staff in the performance of their duties.

7. Ability to multi-task and work effectively in a high-stress and fast-moving environment.

8. Demonstrates cultural humility and sensitive and demonstrated ability and effectiveness in working with ethnically diverse populations and diverse environments.

9. Strong analytical and problem-solving skills.

10. Knowledge and experience with cost and fund accounting.

11. Strong written and verbal communication skills.

PREFERRED QUALIFICATIONS

1. Bachelor’s degree in public health, public administration, public policy, business administration, or related field.

2. Minimum 2 years of experience in healthcare compliance, auditing, and/or quality control in a healthcare setting.

3. Dental and/or medical experience.

4. Experience with accreditation and licensing surveys, i.e. Health Resources and Services Administration (HRSA) Operational Site Visit (OSV); The Joint Commission (TJC); Accreditation Association for Ambulatory Health Care (AACHC); Commission on Dental Accreditation (CODA)

5. Familiarity with compliance systems, such as Compliatric.

6. Project management experience.

PHYSICAL & WORK 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. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.