Compliance Manager in Fresno, California at Sierra Meadows & Ascend Behavioral Health

The Compliance Manager ensures day-to-day organizational adherence to federal, state, and internal regulatory requirements across all TPEG programs. The role centers on reviewing incident reports and auditing programs to maintain ongoing compliance with Joint Commission, DHCS, and DSS standards, and on managing the QAPI process and internal licensing tracking across all sites. TPEG partners with an external national compliance consulting firm, which leads complex contract negotiations, licensing/certification applications, and regulatory audits; the Compliance Manager coordinates closely with that firm, executes on their guidance day to day, and directly supervises the Compliance Assistant in carrying out environmental, vehicle, and site-level compliance auditing. This role is pivotal in fostering a culture of accountability, continuous improvement, and regulatory readiness at the program level.

ESSENTIAL FUNCTIONS:

1. Regulatory Compliance & Oversight

• Review and maintain working knowledge of DSS, JCAHO, California State, DHCS, and insurance regulations; monitor and track current operational licensing, certifications, and accreditations.

• Conduct regular internal and environmental audits, and daily/semiannual/annual audit cycles across all programs, to assess compliance with local, state, and federal regulations and readiness for state and JCAHO inspections. This includes daily review of incident reports to maintain ongoing program-level compliance with Joint Commission, DHCS, and DSS standards.

• Implement compliance procedures and policies developed in collaboration with leadership and the compliance consulting firm; manage updates to program policies and P&Ps in accordance with systemic or regulatory changes, ensuring consistency across all programs.

• Keep abreast of legislative and regulatory changes; disseminate relevant updates and provide regular training to staff.

• Flag County contract terms that may conflict with the organization's operational needs, risk tolerance, or compliance obligations, and route them to the compliance consulting firm and leadership for resolution.

• Support completion and submission of Plans of Correction and ESAs for state and JCAHO audit findings; identify audit trends and collaborate with directors on corrective and improvement plans.

• Manage and maintain all Guardian background checks/clearances and DOJ clearances.

2. Quality Assurance & Performance Improvement

• Manage organizational quality assurance tools and processes, including the QAPI Workbook, day to day across programs.

• Oversee all Unusual Incident Reports — reviewing, providing feedback, editing, and approving prior to state submission to protect clients, staff, and the company; guide management on appropriate follow-up plans after incidents.

• Track compliance documentation for accuracy, timeliness, and completeness across all sites using data metrics.

• Plan and organize semiannual and annual audit tools; facilitate in-house audits, identify trends, provide reports and recommendations to directors, and oversee ongoing corrective activities.

• Track corrective action plans and PIPs to closure and escalate emerging risk promptly to leadership.

• Support environmental safety compliance by tracking, auditing, and following up on environmental documentation and audit results.

3. Contract & Licensing Support

• Support the external compliance consulting firm, which leads licensing and certification applications for new facilities and complex contract negotiations, by coordinating internal information (program descriptions, staffing plans, facility details) needed for those applications and contracts.

• Track all license, certification, and contract renewal deadlines for DHCS, DSS, and JCAHO across all programs; verify facility, staffing, and program information matches actual operations ahead of consultant-led renewals.

• Monitor state and insurance contract terms, requirements, and deadlines, routing negotiation and complex-contract needs to the compliance consulting firm.

• Monitor RFPs and provide a synopsis to the CEO and COO; support the compliance consulting firm's preparation and submission of county RFPs when requested, including portal registrations and uploads.

• Maintain organized digital and physical systems for licensing and contract documentation.

4. Training & Communication

• Provide compliance-related training to staff, including documentation standards, emergency procedures, environmental health and safety, and mandated reporting; deliver new-hire training on DHCS/DSS/JCAHO documentation and reporting standards.

• Serve as a day-to-day point of contact for regulatory inspections and audits, and as liaison between the Compliance Assistant and other functions for integrated, timely responses.

• Schedule and track HR compliance courses required by law (CPI, CPR, mandated reporter, water safety) and audit staff files for state, JCAHO, and HR-required documentation across SharePoint, Paylocity, and the Paylocity Skills tracker.

• Present findings and trends from day-to-day compliance activity to the COO.

5. Investigation & Risk Management

• Respond to and, in collaboration with HR, investigate compliance-related complaints or incidents involving staff behavior or potential misconduct; record and document findings and write investigation reports.

• Implement corrective action plans and trainings, and disciplinary actions when needed, to resolve noncompliance with regulatory standards and procedures.

• Communicate emerging risks to the COO and compliance consulting firm early, along with mitigation plans; support management during state and JCAHO audits.

6. Team Supervision

• Directly supervise the Compliance Assistant, providing guidance, direction, and support to ensure high-quality compliance activities across all sites.

• Mentor the Compliance Assistant on regulatory frameworks, internal controls, and effective stakeholder communication, including oversight of vehicle, fire/CO2, and environmental audits performed across sites.

• Attend Diversity, Equity & Inclusion Committee meetings on behalf of the company as required by county contract.

MINIMUM QUALIFICATIONS:

EDUCATION: Bachelor's Degree in Business, Healthcare Administration, Public Health, or related field.

LICENSURE: N/A

RELATED EXPERIENCE: Five (5) years of experience in healthcare compliance, quality assurance, or licensing; prior experience supervising or mentoring staff preferred given oversight of the Compliance Assistant.

OTHER EXPERIENCE / SKILLS REQUIRED: Strong knowledge of California health care regulations and standards (DHCS, DSS, JCAHO); experience conducting audits and regulatory inspections; comfort coordinating with an external compliance consulting firm on complex contracts, applications, and audits.

• Experience working with culturally diverse individuals and communities or have otherwise demonstrated a commitment to strengthening engagement of a diverse community and skill in communicating with diverse populations.

• Familiarity with equity and/or diversity initiatives within an organization.

• Written and oral communication skills sufficient to perform essential functions.

• Demonstrated ability to make decisions independently and use initiative to accomplish complex assignments with general instruction and guidance.

• Demonstrated ability to exercise judgment and integrity on the job with confidentiality, tact, and diplomacy.

• Demonstrated ability to organize time and other resources to perform multiple tasks.

• Demonstrated ability to complete work accurately and in a timely manner with attention to detail.

• Demonstrated ability to work well with others and to provide effective team leadership.

• Proficiency in word processing and database and/or spreadsheet applications.

• Physical and mental attributes sufficient to perform essential functions.

• Demonstrated ability to recognize merit, excellence and intelligence in staff and potential employees.

• Valid Driver's License

PREFERRED QUALIFICATIONS:

1. Proficient in English Language

2. Proficient communicator

WORKING CONDITIONS:

1. Work settings vary from offices, program sites, and stakeholder locations

2. Travel modes can include the use of company or personal transportation