Compliance Program Manager
1 day ago
Escondido
Job Description About Us Community health is about more than just vaccines and checkups. It’s about giving people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy and happy. We’re with you every step of the way, with the care you need for each of life’s chapters. At Neighborhood, we are Better Together. As a private, non-profit 501(C) (3) community health organization, we serve over 500,000 medical, dental, and behavioral health visits from more than 96k people annually. We do this in pursuit of our mission to improve the health and happiness of the communities we serve by providing quality care to all, regardless of situation or circumstance. We have been doing this since 1969, and it is our employees that make this mission a reality. Regardless of the role, our team focuses on being compassionate, having integrity, being professional, always collaborating, and consistently going above and beyond. If that sounds like an organization you want to be a part of, we would love to have you. ROLE OVERVIEW and PURPOSE The Compliance Program Manager supports Neighborhood Healthcare’s (NH) Corporate Compliance Program by leading policy management, delivering compliance education and training, and conducting risk‑based compliance audits across the organization. This role ensures NH maintains ongoing compliance with HRSA Health Center Program Requirements, federal and state laws, and internal policies. HRSA identifies ongoing compliance, internal monitoring, and documentation as core expectations for FQHCs. This role reports to the Corporate Compliance Officer and works collaboratively with operational, clinical, financial, and quality staff. This role is assigned as Co-Chair of the Compliance Staff Subcommittee as well as the Risk Management Subcommittee. RESPONSIBILITIES Policy Management (Development, Review & Governance) • Maintain the organization’s library of policies and procedures and ensure policies remain aligned with HRSA requirements, including HRSA’s specific expectations for Board‑approved and operational policies., • Oversee scheduled policy reviews (at least every three years or more frequently if required by federal/state regulations) in conjunction with Compliance & Risk Coordinator., • Draft, revise, and standardize policies in collaboration with subject matter experts as needed., • Ensure policies reflect updated federal regulations and HRSA’s Compliance Manual, including terminology and regulatory citation changes (e.g., updates to Uniform Guidance per the 2025 Compliance Manual revision)., • Maintain proper version control and documentation standards. Compliance Education & Training • Develop, monitor, and track compliance training programs for all staff as needed, consistent with ongoing compliance expectations in HRSA’s Compliance Manual., • Monitor onboarding compliance training for new employees and role‑specific training for leadership, clinical providers, billing teams, and administrative staff., • Ensure staff understand key compliance risks including HIPAA privacy/security, billing/coding integrity, Scope of Project limits, Sliding Fee Discount Program requirements, FTCA, and 340B., • Develop educational materials (e.g., toolkits, presentations, staff messages, job aids)., • Track training completion and report gaps to the Corporate Compliance Officer. Compliance Auditing & Monitoring • Oversee existing, and conduct as needed, routine and risk‑based internal audits across operational, clinical, and/or financial domains, aligning with HRSA’s expectation that health centers perform internal monitoring and demonstrate ongoing compliance., • Audit areas include:, • Sliding Fee Discount Program, • Billing and coding compliance, • HIPAA Privacy/Security, • Credentialing and privileging documentation, • FTCA risk management elements, • 340B procedures (if delegated by pharmacy/340B team), • UDS data integrity and reporting workflows, • Prepare written audit reports summarizing methodology, findings, and recommendations based on departmental compliance audit reports., • Track and validate departmental corrective action plans (CAPs), ensuring timely follow‑through. Regulatory & HRSA OSV Readiness Support • Maintain readiness for the HRSA Operational Site Visit (OSV) by ensuring required documents, sample lists, and policies meet the structure and content expectations outlined in the Site Visit Protocol. HRSA’s Site Visit Protocol lists required assessments, documentation reviews, and demonstrating compliance elements., • Assist with collecting, organizing, and naming evidence according to HRSA’s Required Documents & File Naming Convention guidance., • Support mock OSV assessments and coordinate with internal stakeholders to resolve identified gaps. Compliance Program Operations • Support the Compliance Officer in day‑to‑day operations of the Corporate Compliance Program., • Research and respond to compliance related questions from the organization’s staff., • Track trends of internal compliance concerns; assist Risk Manager with clinically related investigations., • Maintain compliance logs as needed (e.g., audit logs, policy review logs, CAP tracking tools)., • Prepare quarterly compliance dashboards and reports for the Compliance Staff Subcommittee, Risk Management Subcommittee, Corporate Compliance Committee and Board of Directors., • Assist with updating the annual Compliance Work Plan. EDUCATION/EXPERIENCE • Bachelor’s degree in healthcare administration, Public Health, Compliance, Nursing, or related field required., • Minimum of 4 years of experience in healthcare compliance, nursing, administration, or quality required; preferably in an FQHC setting., • Familiarity with HRSA Health Center Program Requirements and Site Visit Protocol is strongly preferred., • Clinical experience strongly preferred ADDITIONAL QUALIFICATIONS (Knowledge, Skills and Abilities) • Demonstrates high integrity and ethical conduct, • Detail-oriented with strong follow-through, • Collaborative, supportive, and mission-driven, • Thrives in fast-paced, evolving regulatory environments, • Strong verbal and written communication skills, including composition and proofreading, • Able to interpret and apply written, oral, and visual instructions, • Effectively manages multiple priorities and deadlines, • Strong planning and organizational skills, • Works both independently and collaboratively, • Ability to lift/carry 10 lbs/weight (documents and training materials., • Ability to attend onsite audits, meetings, and training sessions as needed. COMPLIANCE (Safety & HIPAA) • Follows all safety procedures as outlined in Neighborhood Healthcare’s Illness and Injury Prevention Plan (IIPP) and report any injuries and/or unsafe conditions immediately, • Maintains current knowledge of policies and procedures as they relate to safe work practices, • Follows all safety procedures and reports unsafe conditions, • Uses appropriate body mechanics to ensure an injury free environment, • Familiarity with location of nearest fire extinguisher and emergency exits, • Follows all infection control procedures including blood-borne pathogen protocols, • Maintains privacy of all patients, employees and volunteer information and access such information only on a need-to-know basis for business purposes, • Comply with all regulations regarding corporate integrity and security obligations Pay range: $104,200.00 to $156,200.00, depending on experience and additional qualifications. Compensation Disclosure: The posted salary range reflects the designated pay grade for this position. While this range represents the broader classification of the role, actual compensation will be based on several factors, including but not limited to: the candidate’s overall knowledge, skills, and experience, market data and industry benchmarks, internal equity within the organization, Budgetary considerations and organizational needs. As a result, placement within the range is not guaranteed, and the full pay grade range may not be utilized.