Compliance Coordinator
5 days ago
Fayetteville
Job Description Summary: The Compliance Coordinator is responsible for building, implementing, and sustaining Southeastern Integrated Care’s organizational compliance program across regulatory, privacy, and policy functions. This role owns the day-to-day operation of the compliance infrastructure — including HIPAA Privacy and Security, OIG exclusion monitoring, policy and procedure management, vendor oversight, staff compliance training, and the Human Rights Committee — and serves as the organization’s primary operational compliance resource. The Compliance Coordinator works closely with the Director of QM/UR/Compliance to ensure SEIC meets all federal, state, and Medicaid/Medicare regulatory requirements and is positioned for continued growth, CCBHC certification readiness, and potential accreditation. This is a new position that requires someone equally comfortable building infrastructure from the ground up and managing ongoing compliance operations with precision and accountability. Essential Duties and Responsibilities: Regulatory Compliance Program Management • Oversee SEIC’s compliance with applicable federal, state, and payer regulations — including NC Medicaid Managed Care behavioral health requirements, Medicare conditions of participation, and NC DHHS licensing standards., • Monitor the regulatory environment for changes affecting SEIC’s service lines (SAIOP, SACOT, ACTT, CST, IIH, MST, Residential, Mobile Crisis, Primary Care, Learning Center) and communicate material updates to the Director and relevant program staff., • Maintain a compliance calendar tracking all regulatory reporting deadlines, review cycles, and renewal requirements to ensure nothing falls through the cracks., • Serve as SEIC’s designated HIPAA Privacy Officer (or support that function as directed), responsible for implementing and maintaining the organization’s HIPAA Privacy and Security program., • Manage the annual HIPAA training cycle — develop or update training content, assign to all staff, track completions, and document for audit purposes., • Lead HIPAA breach response: assess incidents using the four-factor risk assessment, make notification determinations, coordinate required notifications to affected individuals and HHS/OCR, and maintain the breach log., • Execute and maintain Business Associate Agreements (BAAs) for all applicable vendors and contractors; track expiration dates and ensure renewals or terminations are handled on schedule., • Own and manage SEIC’s policy and procedure library — maintain a master policy calendar with review dates, assign policies to subject matter experts for review, route through approval, publish, and archive prior versions., • Draft new policies and procedures as regulatory requirements, operational changes, or audit findings create the need; ensure all policies are written in plain language and are operationally actionable., • Ensure policies are accessible to staff and that new or revised policies are communicated and documented., • Conduct monthly OIG exclusion list checks for all employees, contractors, and vendors against the HHS List of Excluded Individuals/Entities (LEIE) and SAM.gov., • Document all monthly screening results; immediately escalate any matches to the Director and HR for investigation and required action., • Develop and deliver the annual compliance training program for all SEIC staff — covering the Code of Conduct, HIPAA, fraud/waste/abuse, incident reporting obligations, and program-specific regulatory requirements., • Coordinate and deliver compliance orientation for all new employees as part of onboarding, including incident reporting procedures and HIPAA basics., • Co-lead the Human Rights Committee with the QI Coordinator — prepare meeting materials, ensure quorum, facilitate agenda, document minutes, and track action items to closure., • Ensure HRC meetings occur at the required minimum quarterly frequency and that documentation is maintained in a format that supports regulatory review., • Oversee SEIC’s compliance-related incident reporting processes — ensuring staff understand reporting obligations and that all reportable events are documented, investigated, and escalated appropriately., • Track compliance-related corrective action plans (CAPs) — document findings, assign responsible parties, monitor implementation, and verify closure with supporting evidence., • Review new vendor and contractor relationships to determine whether a BAA or other compliance agreement is required; execute agreements and log all compliance-relevant contract terms., • Serve as a compliance resource and advisor to program directors, clinical supervisors, and administrative staff across all SEIC service lines., • Maintain regular communication with the Director of QM/UR/Compliance regarding open compliance issues, regulatory developments, and program status., • Participate in QI Committee meetings as a compliance subject matter resource., • Participate in team meetings, training, and departmental process improvement initiatives. Key Performance Indicators (KPIs) • OIG exclusion screening: 100% of employees, contractors, and vendors screened monthly; zero gaps in the screening log; all matches escalated within 1 business day of detection., • HIPAA training completion: 100% of staff complete annual HIPAA training by the designated deadline; new hire completion within the first 30 days of employment., • Compliance training completion: ≥95% organizational completion rate for annual compliance training by deadline; completion rates reported to the Director monthly during the training window., • Policy calendar adherence: 100% of policies reviewed on schedule per the annual policy calendar; no policy overdue for review by more than 30 days., • BAA/vendor compliance log: All active vendors with PHI access covered by a current, executed BAA; zero lapsed agreements outstanding for more than 10 business days., • Breach response timeliness: All potential HIPAA incidents triaged within 1 business day of identification; risk assessments completed and documented within 10 business days; required notifications issued within regulatory deadlines., • HRC meeting cadence: Human Rights Committee convenes at minimum quarterly; 100% of meetings documented with minutes and action items within 5 business days of each meeting., • Corrective action plan closure: ≥80% of open compliance CAPs closed within the agreed-upon timeframe; all overdue CAPs flagged to the Director with a remediation plan., • Regulatory calendar compliance: Zero missed regulatory reporting deadlines or licensing renewal dates within the Compliance Coordinator’s scope of responsibility. Qualifications: Education/Experience Required • Bachelor’s degree required in healthcare administration, health information management, public health, business, or a related field., • Minimum 3 years of experience in healthcare compliance, with direct responsibility for HIPAA, regulatory compliance, and/or policy management., • Working knowledge of federal and North Carolina behavioral health regulatory requirements, including Medicaid/Medicare conditions and NC DHHS licensing standards., • Demonstrated experience managing HIPAA Privacy and Security functions, including breach response and risk assessment., • Experience developing and delivering compliance training programs., • Strong policy writing skills — ability to translate regulatory requirements into clear, operationally usable policies and procedures., • Highly organized with the ability to manage multiple compliance obligations simultaneously and maintain audit-ready documentation at all times., • Certified in Healthcare Compliance (CHC) credential, or actively working toward it., • Master’s degree in health administration, public health, healthcare compliance, or a related field., • Experience in a CARF-accredited or CCBHC-certified behavioral health organization., • Familiarity with NC Medicaid Managed Care behavioral health benefit requirements and payer compliance expectations. This position reports directly to the Director of QM/UR/Compliance and is housed within the Quality Management, Utilization Review, and Compliance Department. The Compliance Coordinator operates as the department’s senior compliance resource and works in close coordination with the Compliance Specialist, who handles incident reporting, grievance processing, and related front-line compliance functions. The Compliance Coordinator does not carry supervisory authority over other department staff but is expected to provide guidance, direction, and compliance expertise across all SEIC service lines and departments. This role interfaces regularly with HR, program directors, billing, and clinical leadership. Supervisory Responsibilities: None Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. This position is primarily remote. The employee is expected to maintain a dedicated, distraction-free home workspace with reliable high-speed internet access sufficient to support EHR use, payer portal access, and video conferencing. Bi-weekly on-site presence at Southeastern Integrated Care locations may be required for onboarding, team meetings, training, or operational needs as determined by the Director. The role requires sustained focus, deadline management, and the ability to handle a high volume of electronic correspondence, portal submissions, and documentation tasks independently. 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. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit; use hands to operate a computer keyboard and phone; talk and hear. The employee is occasionally required to stand, walk, reach, and lift materials up to 15 pounds. Specific vision abilities required include close vision and the ability to adjust focus for extended screen use.