POSITION SUMMARY:

The Director of Compliance and Risk Management is responsible for overseeing and managing the organization's compliance and risk management program, ensuring adherence to regulatory requirements and internal policies. This role plays a critical part in maintaining organizational integrity by implementing compliance strategies, risk management processes, and contract oversight. The Director of Compliance and Risk Management collaborates closely with the senior leadership team to develop, implement, and monitor compliance initiatives, ensuring the organization meets the Seven Elements of an Effective Compliance Program.

ESSENTIAL DUTIES & RESPONSIBILITIES:

• Lead and chair the Compliance Committee, ensuring effective oversight and implementation of compliance policies.
• Develop and maintain a comprehensive FQHC Compliance Program in alignment with Section 330 of the Public Health Services Act and HRSA’s Health Center Program Compliance Manual.
• Oversee and manage contract compliance, risk management, and adherence to federal, state, and local regulatory requirements, including but not limited to HIPAA, 340B, HRSA and OSHA.
• Establish, maintain, and update essential compliance policies, including but not limited to HIPAA, Safety, 340B, Risk Management, and Emergency Preparedness.
• Design and implement an annual audit plan targeting high-risk areas such as billing, coding, documentation, HIPAA, investigations, cybersecurity, fraud prevention, grants management, and revenue protection.
• Conduct annual HIPAA risk assessments, ensuring compliance with Security Rule administrative, physical, and technical safeguards.
• Develop and enforce employee compliance training programs, ensuring all staff members receive legally mandated and policy-required training.
• Oversee the monitoring and tracking of critical compliance requirements including employee attestations, performance evaluations, incident reporting, onboarding, CME and tuition reimbursement requests, and other policy requirements.
• Investigate and document incidents, escalating significant matters to the Chief Executive Officer as needed.
• Ensure effective compliance assessments of employees, clinical staff, and contractors by regularly reviewing the National Practitioner Data Bank, state licensure records, HHS-OIG’s List of Excluded Individuals/Entities, and GSA’s debarred parties list.
• Maintain compliance with accreditation and regulatory standards by assessing staff competencies and addressing any compliance deficiencies.
• Manage the organization’s risk management program, proactively identifying and mitigating legal risks.
• Collaborate with external auditors and regulatory bodies for audits or to address compliance-related matters.
• Effectively fulfill responsibilities of the organization’s Safety Officer, ensuring safety protocols, drills, and emergency preparedness plans are up to date and effectively implemented.