Director of Compliance and Risk Management

Position Summary: The Director of Compliance and Risk Management is responsible for leading, coordinating, and enhancing the organization's compliance, risk, licensing, and accreditation programs. This role will ensure adherence to federal, state, and local regulations, safeguard the organization's integrity, and foster a culture of ethical behavior, safety, and continuous improvement. The Director will work closely with various regulatory bodies, lead audits, and provide guidance across all departments to align practices with industry standards.

As a full time, Director of Compliance and Risk Management, you will be offered the following benefit options:

• Medical
• Dental
• Vision
• Supplemental Life
• Disability
• 401k
• Personal PTO
• Vacation Time
• Employee Assistance Program

Key Responsibilities include but are not limited to:

Regulatory Compliance:

• Ensure the organization complies with applicable laws, regulations, and industry standards.
• Oversee the development, review, and implementation of compliance policies and procedures.
• Stay updated on regulatory changes, advising leadership on necessary adjustments.

Licensing and Certification

• Monitor licensure and certification statuses, ensuring compliance with all regulatory requirements and proactively submitting applications to the Department of Children & Families (DCF), Agency for Healthcare Administration (AHCA), Department of Health, and local occupational licensing authorities.
• Organize, file, and maintain compliance documentation for all licensure and certification, ensuring records are readily accessible and up-to-date.
• Develop, update, and support policies and procedures in line with DCF, AHCA, Department of Health, OSHA, CARF, and Joint Commission standards.
• Serve as the primary contact for all licensure and certification surveys and lead all interactions with regulatory bodies.
• Collaborate with departments to ensure compliance with guidelines covering clinical care, environment of care and safety, and performance improvement initiatives.
• Liaise with governing bodies on policies affecting patient rights and address any investigations that may arise.
• Coordinate site visits, compliance checks, and documentation reviews for external stakeholders, including CARF, OSHA, Department of Health, and DCF.

Accreditation Management

• Monitor and maintain the organization's accreditation status, managing applications and updates with the Joint Commission and CARF for Behavioral Health and Opioid Treatment Program accreditation.
• File, organize, and maintain accreditation records, ensuring compliance with all required guidelines and standards.
• Support and uphold policies and procedures as dictated by DCF, CARF, ACHA, Department of Health, and Joint Commission accreditation standards.
• Lead the organization through all accreditation and compliance surveys, ensuring readiness for each review.
• Coordinate site visits, compliance activities, and documentation review for external stakeholders, including federal and state agencies, to uphold accreditation standards.

Policy Development & Enforcement:

• Develop and update organizational policies related to compliance and risk.
• Enforce adherence to policies through education, regular audits, and corrective actions.
• Lead initiatives to strengthen a culture of compliance across the organization.

Compliance Program Development and Oversight

• Develop and implement policies, procedures, and strategies covering Risk Management, Quality Improvement, Dietary, Housekeeping, Environment of Care (Safety, utilities, life safety, medical equipment, hazardous materials, etc.), and Clinical Operations.
• Identify compliance vulnerabilities and recommend corrective actions to resolve issues, working to prevent recurrence and guide future decision-making.
• Lead the development of a compliance training program, providing onboarding for new hires and ongoing education for staff and management.
• Monitor compliance activities organization-wide, enhancing and standardizing compliance-related practices to improve organizational performance and adherence to regulations.

Compliance Standards and Support:

• Assist teams in understanding and implementing assessment techniques, including criteria development, data analysis, and confidentiality of performance improvement data.
• Ensure continuous compliance with agency, state, and federal regulations, adapting policies and procedures to meet evolving requirements.
• Prepare, review, and submit compliance reports to governing bodies, administration, medical staff, and external agencies promptly.

Risk Management & Incident Response:

• Lead investigations into compliance-related incidents and ensure proper documentation.
• Work closely with relevant departments to address and resolve issues.
• Implement corrective actions and oversee follow-up processes.
• Direct the Risk Management Department to meet all regulatory and licensing standards. Serve as the facility's Licensed Healthcare Risk Manager, coordinating and evaluating the organization's internal risk management program.
• Lead the development and implementation of risk management training for new hires, with regular updates for all staff.
• Investigate allegations and incidents, collaborating with law enforcement on cases involving abuse and sexual misconduct as needed.
• Oversee the internal and external reporting system, ensuring compliance with the Internal and external Risk Management Policy and documenting any incidents accurately.
• Develop and implement comprehensive risk management strategies and frameworks.
• Identify potential risks in operations, financials, IT, and other key areas.
• Lead risk assessments and regularly monitor the organization's risk exposure.
• Recommend measures to mitigate and manage risks effectively.

Performance Improvement and Compliance Reporting

• Guide performance improvement activities, including data collection, analysis, and reporting, to drive informed decisions and improve compliance practices.
• Generate and review monthly, quarterly, and annual data reports, presenting metrics for compliance and identifying areas needing improvement.
• Maintain confidential patient information and ensure compliance with all confidentiality regulations.
• Respond to compliance violations by evaluating and recommending corrective procedures, ensuring accurate documentation and accountability.
• Collaborate with Department Heads to form work groups to investigate issues, develop solutions, and generate required reports.
• Serve as an Ad Hoc member on various Quality Improvement committees, including Nursing, Medical Staff, Risk Management, Safety, Pharmacy, Therapeutic, and Infection Control committees.
• Regularly report on compliance status, risk exposure, and mitigation efforts to executive leadership.
• Collaborate with internal and external auditors, regulatory bodies, and legal teams.
• Provide transparent and actionable insights to the Board on compliance and risk matters.

Qualifications:

• Bachelor's degree in Business, Healthcare Administration, Law, or related field; advanced degree or certifications (e.g., CRMP, CCEP, LHCRM) preferred.
• Minimum of 8-10 years of experience in compliance, risk management, or regulatory oversight in healthcare or a related industry.
• Strong knowledge of healthcare regulatory and accreditation requirements (e.g., DCF, AHCA, Joint Commission, CARF, Department of Health, OSHA).
• Proven leadership experience with the ability to mentor and develop a compliance-focused team.
• Excellent communication, analytical, and problem-solving skills.
• Strong organizational skills with attention to detail and the ability to handle confidential information responsibly.

Key Competencies:

• Strategic Thinking and Decision-Making
• Attention to Detail
• Integrity and Ethical Judgment
• Strong Organizational and Project Management Skills
• Ability to Handle Confidential Information Responsibly