Compliance Manager

Position Title: Compliance Manager Reports To: Chief Pharmacy Officer FLSA Status: Full-Time

Location: Sanford

Content Last Revised: 10/19/2024

ORGANIZATION OVERVIEW

The Central Florida Family Health Center, Inc. dba True Health is a private, not-for-profit federally qualified health center (FQHC) serving Central Florida since 1977. Our mission is to provide high-quality, comprehensive healthcare at a reasonable cost to everyone.

JOB SUMMARY

Responsible for leading the implementation and management of compliance of local, federal, and state laws; regulatory and accreditation guidelines; as well as the Centers for Medicare and Medicaid Services requirements; Collaborate with all departments to ensure that activities and operations adhere to internal policies and external regulations; Ensure compliance and organizational adherence with the Health Insurance Portability and Accountability Act

(HIPAA); Monitor and report results of audits, inquiries, investigations, and status on areas of responsibility and provides guidance for the senior management team.

KEY RESPONSIBILITIES

• Develops, initiates, maintains, and revises organizational compliance management programs including but not limited to associated training, policies, and procedures
• Trains and coaches staff in areas of compliance related responsibilities and practices
• Collaborate with all departments to address compliance related issues
• Collaborate with leadership and support teams to achieve organizational compliance goals
• Acts as the organization lead for implementing compliance programs, audits, education, training requirements, and other related compliance efforts
• Develops and maintain a compliance committee in order to lead the analysis of audit completion and outcomes across all departments
• Leads all surveys and site visits to include but not limited to Health Resources and Services Administration (HRSA) and Accreditation Association for Ambulatory Health Care (AAAHC) site visits in collaboration with the Risk Manager
• Responsible to drive the compliance of annual review of policies and procedures in tandem with senior leadership
• Responsible to lead organizational compliance with the Federal Tort Claims Act (FTCA) program and all required activities throughout the year
• Responsible for the completion, preparation, and submission of FTCA requirements
• Responsible for leading and assessing completion of safety and emergency related drills as well as periodic regulatory inspections
• Follows up on drill and inspection outcomes to ensure resolution of deficiencies
• Collects, manages, and evaluates appropriate documentation related to clinical education, and other related training programs to ensure all training requirements are met in relation to regulations, accreditations, contractual obligations, etc
• Ensures that compliance issues and concerns are appropriately evaluated, investigated, and resolved in a timely manner
• Continuously analyze and identify potential areas of clinical and organizational compliance vulnerability in order to develop and implement corrective action plans for resolution of problematic issues and provide general guidance on how to avoid or address similar situations in the future
• Demonstrates proficiency in computer systems and software used to track compliance data and generate exception reports.
• Possess expert level knowledge of healthcare and organizational associated regulations at the federal, local, and state levels, as well as accreditation regulations and standards
• Prepares and presents accurate and professional reports and documents for any assigned meetings
• Participates in all assigned meetings including project-specific meetings.
• Provides reports on a regular basis, and as directed or requested, keeping the senior management team informed of the operation and progress of compliance efforts.
• Ensure proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate or required
• In coordination with the IT Department, helps to ensure alignment between security and privacy practices to ensure HIPAA adherence
• Responsible for compliance related records retention either by electronic and/or hard-copy
• Responsible to review agreements and/or contractual documents to ensure standard organizational compliance
• Acts as a liaison with organization's corporate attorneys as needed for compliance related items
• Must have reliable transportation and be able to travel to all organizational sites/activities as needed
• Must be available to lead compliance related items outside of regular business hours
• Must be available to participate in community participation events during and outside of regular business hours and days
• Perform other duties as assigned.

ESSENTIAL FUNCTIONS

• Strong Attention to Detail
• Problem Solving
• Critical Thinking
• Independent Work
• Effective Collaboration
• Project Management
• Customer Service
• Professional Verbal Communication
• Excellent Written Communication Skills
• Leadership
• Professional Judgement
• Planning/Organizing
• Quality Control
• Safety/Security
• Adaptability
• Initiative
• Innovation
• Strategic Planning
• Administration/Operations
• Leadership Skills
• Vision

Minimum Qualifications

• Education: Bachelor's degree in Clinical Services Management, Healthcare Administration, Law, Business Administration, or a related field required; Master's degree highly preferred.
• Experience: Minimum of 5 years in related healthcare compliance roles; Minimum of 5 years in healthcare management roles; Minimum of 5 years with electronic health records (EHR) systems; Federally Qualified Health Center (FQHC) experience preferred; Previous experience in clinical care settings preferred

Licenses or Certifications:

Certified Professional in Healthcare Compliance required

Certified HIPAA Professional or Certified in Healthcare Privacy Compliance required

OSHA Certificate/Training Program completion preferred

Clinical License preferred

True Health is a Health Center Program grantee under 42 U.S.C. 254b, a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n), and partners with agencies that require criminal background checks. True Health has established policies and procedures that may influence the overall employment process,hiring, and "just cause" for the termination of employees. An employee's career could be shortened if there is a violation of any policies and procedures. Significant conviction is defined as a conviction or under indictment for any felony, conviction and/or incarceration for any misdemeanors within the last ten (10) years, or conviction and/or incarceration of any computer crime.

Any employee arrested under the auspices of significant conviction records as listed above will be immediately suspended and remain suspended until the charges are disposed of in court. The employee will be terminated for an arrest or conviction of any violation listed above.

DRUG/ALCOHOL SCREENINGS

A post-offer drug and alcohol screen is a requirement for employment. Failure to successfully pass the drug/alcohol screen will be cause for the offer to be rescinded. Employees are subject to random drug/alcohol screenings throughout the duration of their employment with True Health. If an employee fails to pass the drug/alcohol screening, then this shall become grounds for discipline up to and including immediate termination.

WORK ENVIRONMENT

• The employee is subject to prolonged periods of sitting at a desk and working on a computer.
  • The employee is subject to prolonged periods of walking and standing.
  • The employee is subject to perform repetitive hand and wrist motions.
• The employee is frequently required to stand, walk, talk, and hear.
  • The employee is occasionally required to use hands to handle or feel objects, reach with hands and arms, stoop, kneel, crouch, and move or lift up to twenty-five (25) pounds.
  • The employee is required to use close vision, peripheral vision, depth perception, and adjust focus.
  • A reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

WORKING CONDITIONS

The employee will work as the needs of the operation require. True Health's standard working hours/business operations occur during the hours of Monday- Saturday from 8:00am - 6:00pm.