Compliance Manager

The Compliance Manager is responsible for the day‑to‑day management and execution of the organization’s compliance, privacy, and regulatory support activities. This role ensures ongoing adherence to HRSA Health Center Program requirements, HIPAA, FTCA‑related compliance obligations, payer requirements, and other applicable federal and state laws governing a Federally Qualified Health Center (FQHC).

The Compliance Manager operates as a hands‑on subject matter expert and program owner, working collaboratively with clinical, operational, and administrative teams to implement compliance processes, monitor adherence, investigate concerns, and maintain audit readiness. The role supports continuous compliance through structured monitoring, documentation management, staff education, and corrective action tracking, while exercising appropriate independence to raise and address compliance issues.

Essential Values-Based Competencies: Demonstrates values-based competencies in line with the four core values that are the foundation of all activities performed by employees in order to achieve the mission of the health center.

Dignity: Demonstrates competence in communication and interpersonal relations

Excellence: Demonstrates competence in continuous improvement, continuous learning, and teamwork/collaboration

Service: Demonstrates competence in customer/patient focus, adaptability, and shaping change

Justice: Demonstrates competence in community orientation, stewardship, and strategic planning and action

 Essential Functions: 

Compliance Program Execution

• Manage the day‑to‑day operation of the organization’s Compliance Program in alignment with HRSA, CMS, OIG, California DHCS, FTCA, and HIPAA requirements.
• Prepare an annual risk assessment and related compliance workplan, including scheduled monitoring, audits, follow‑up activities, and documentation.
• Identify compliance risks and gaps through audits, reviews, trend analysis, and operational engagement; recommend mitigation strategies to leadership.
• Maintain confidential reporting channels for compliance concerns and ensure concerns are addressed in accordance with policy and non‑retaliation standards.
• Monitor regulatory changes and support translation of requirements into operational guidance and tools.
• Prepare and present regular compliance reports and summary dashboards for the Board and/or Board Committees, including key risks, trends, and status of corrective actions

Auditing, Monitoring & Spot Checks

• Conduct or cause to occur internal audits and compliance reviews of identified high-risk areas, including but not limited to the following: 
  1. Coding and billing compliance
  2. Clinical documentation
  3. UDS reporting and data integrity
  4. Sliding fee discount program compliance
  5. Credentialing and privileging processes
• Perform periodic spot checks of departmental practices to assess compliance between formal audits. 
• Document findings, develop corrective action recommendations, and track progress in collaboration with responsible leaders.
• Maintain audit files, logs, and evidence demonstrating sustained compliance.

Risks, Incidents & FTCA Related Support

• Manage incident reporting processes related to compliance, privacy, quality, and patient safety events. 
• Conduct or coordinate root cause analyses and track corrective actions to completion. 
• Support FTCA-related compliance activities, including documentation, coordination with claims administrators or legal counsel, and maintenance of required records. related compliance activities, including documentation support, coordination with claims administrators or legal counsel, and maintenance of required records.
• Monitor trends in incidents and compliance concerns and communicate findings to leadership.

Regulatory Readiness & OSV Support

• Serve as a key operational contact for HRSA Operational Site Visits (OSVs) and other regulatory or accreditation reviews.
• Manage the collection, organization, and internal review of OSV‑required documentation, including adherence to HRSA document lists and file‑naming conventions.
• Maintain readiness through ongoing documentation review, internal checklists, and mock reviews as needed.
• Track findings, corrective actions, and follow‑up requirements to support sustained compliance.

Privacy & HIPAA Management

• Serve as the organization’s HIPAA Privacy Officer and/or Security Officer, as assigned.
• Manage privacy policies, procedures, training materials, and Business Associate Agreements (BAAs).
• Receive, investigate, and document privacy incidents and potential breaches, including risk assessment, mitigation, notification coordination, and corrective actions.
• Coordinate privacy and security safeguards with IT, Operations, and clinical leadership.
• Maintain documentation and records required for privacy compliance and audits

Internal Reporting Systems and Documentation

• Administer internal compliance reporting and tracking systems used for intake, investigation, documentation, and resolution of compliance concerns.
• Ensure consistent documentation standards for incidents, investigations, corrective actions, and audits.
• Analyze reporting data to identify trends, recurring issues, and compliance priorities.
• Maintain organized records to support audits, OSVs, and leadership reporting.

Training & Education

• Develop and deliver compliance and privacy training content for onboarding, annual training, and targeted education.
• Provide practical guidance to staff and leaders on regulatory requirements, audit findings, and compliance expectations.
• Reinforce ethical conduct, accountability, and adherence to organizational policies through education and consultation.

Policy & Procedure Administration

• Coordinate the development, review, revision, and implementation of compliance‑ and privacy‑related policies and procedures.
• Manage the policy review calendar and ensure timely updates based on regulatory changes.
• Maintain centralized access to current policies and support departments in operationalizing requirements.

Collaboration, Authority & Communication

• Collaborate with Operations, Finance, Medical, Dental, Behavioral Health, Nursing, Quality, HR, and IT teams to support compliance across service lines.
• Communicate findings, risks, and recommendations clearly to leadership and stakeholders.
• Authorized to access records, staff, and documentation across all service sites and departments as necessary to assess and support compliance with Health Center Program requirements.
• Escalate significant compliance concerns appropriately and in a timely manner

Minimum Position Qualifications:.

• Education:  Bachelor’s degree required
• Experience / Training:  5-8 years of healthcare compliance, privacy, and/or regulatory experience

Preferred Position Qualifications:  

• Education: Master’s degree or advanced professional degree preferred
• Experience / Training:  FQHC healthcare experience strongly preferred
• License / Certification: CHC, CHPC, CCEP, CPHRM, or similar

Physical and Personal requirements: 

• Able to work at various health center locations as needed
• Must have reliable transportation to report for shifts.