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Asian Health Services

Posted 12 days ago

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Compliance Department Manager

OaklandOn-siteFull-time

AI Summary

The Compliance Department Manager develops, implements, and oversees compliance, regulatory, and risk management programs; coordinates audits and accreditation activities; manages policies, training, and data systems; and supervises Compliance Department staff.

About this role

Asian Health Services, founded in 1974, provides medical, dental, and behavioral health services to more than 50,000 patients. Our approach to well-being focuses on “whole patient health” for all. We go beyond our clinic walls and invest in our community’s overall health. We know that income, housing, and environmental struggles lie at the heart of poor health. That’s why we also address food insecurity, youth leadership, and culturally competent care while working towards supporting safer streets and vibrant communities.

Job Summary:

The Compliance Department Manager (CDM) is responsible for developing, implementing, and overseeing the organization’s compliance, regulatory affairs, and risk management programs to ensure adherence to all applicable federal, state, and local laws, healthcare regulations, accreditation standards, contractual obligations, and organizational policies. The CDM partners with leadership and departments by monitoring regulatory changes, engaging key leadership to ensure audit readiness, mitigating organizational risk, and fostering a culture of compliance, accountability and continuous improvement. The Compliance Department Manager works collaboratively with organizational leadership and cross-functional teams to support regulatory reporting, policy governance, compliance monitoring, licensing activities, accreditation readiness, staff education, contract administration, and risk management functions. The Compliance Department Manager supervises staff in the Compliance Department. This position reports to the Chief Administrative Officer (CAO).

Essential Job Functions:

Regulatory Compliance & Program Oversight

  • Ensure organization-wide compliance with federal, state, and local regulations, including but not limited to Health Resources and Services Administration (HRSA) Health Center Compliance Program requirements, Health Insurance Portability and Accountability Act (HIPAA) Privacy, 340B, and credentialing/privileging standards.
  • Oversee compliance with Centers for Medicare & Medicaid Services (CMS) program requirements, including maintenance and revalidation of provider and site information (e.g., CMS PECOS).
  • Ensure accuracy and compliance in regulatory reporting systems (e.g., HRSA Office of Pharmacy Affairs, FTCA EHB portals, etc).
  • Develop, implement, and manage the Annual Compliance Plan in collaboration with the CAO.
  • Foster a culture of accountability, ethical conduct, transparency, and continuous improvement in compliance practices.

    • Audit, Monitoring & Accreditation

    • Lead planning, coordination, and execution of internal and external audits by engaging key stakeholders across departments (e.g., HRSA Operational Site Visits, Federal Tort Claims Act (FTCA) reviews, California Department of Health Services audits, accreditation surveys, and others as applicable.)
    • Guide departments in audit preparation, documentation, and readiness activities.
    • Review audit materials, ensure compliance with requirements, and oversee engagement of key stakeholders to ensure timely follow-up on findings and corrective actions.
    • Oversee activities related to:
      • HRSA Operational Site Visits (OSV)
      • Federal Tort Claims Act (FTCA) reviews
      • Department of Health Care Services audits
      • Internal agency audits (i.e. HIPAA security, credentialing and privileging, enrollment eligibility and contracts/BAAs)
      • Accreditation surveys, including AAAHC, CODA, and other applicable accrediting organizations
      • Support activities related to other regulatory audits that involve other agency departments (i.e. clinic services, QI/QA, HR, Fiscal)
      • Partner with clinical, operational, fiscal, and administrative departments to:
        • Integrate compliance into workflows
        • Support audits, licensing, and regulatory submissions
        • Implement corrective action plans and process improvements

          • Risk Management

          • Oversee the organization’s risk management program, including:
            • HIPAA privacy compliance activities, including breach assessment, incident investigation, and notification requirements.
            • Incident reporting concerning claims management and risk mitigation initiatives
            • Insurance program management and renewals, in collaboration with Facilities Director
            • Federal Tort Claims Act (FTCA) application preparation and submission requirements
            • Risk management training and education initiatives
            • Ensure compliance and risk issues are appropriately escalated, investigated, documented and resolved through established channels.

              • Policies, Procedures & Contract Administration Training and Support

              • Develop, implement, and maintain organizational policies and procedures.
              • Maintain centralized systems for policy management, version control, accessibility, and audit readiness
              • Partner with department leaders to develop compliant operational procedures and workflows
              • Ensure policies remain current and aligned with regulatory, accreditation and contractual requirements.

                • Training, Education & Organizational Support

                • Develop, coordinate, and deliver compliance, privacy, risk management, and regulatory training programs.
                • Provide consultation and guidance to leadership, managers, and staff regarding compliance requirements and best practices.
                • Serve as an internal resource on regulatory matters affecting Federally Qualified Health Centers, including HRSA requirements, HIPAA, Medicare, Medicaid/Medi-Cal, and other applicable healthcare regulations.
                • Promote organizational awareness of compliance obligations and risk mitigation strategies.
                • Support the development and delivery of compliance and risk management training programs.
                • Maintain ongoing competence and serve as a resource on issues relating to compliance, including regulations that apply to FQHCs, such as HIPAA, managed care and HRSA regulations.

                  • Data Management, Reporting & Systems

                  • Oversee compliance systems (e.g., Compliatric) for data collection, validation, tracking, and reporting.
                  • Develop and maintain data repositories and reporting systems to meet regulatory and accreditation requirements.
                  • Analyze compliance and risk data and prepare reports, dashboards, and presentations for leadership, Board, and key stakeholders.

                    • Licensing, Contracts & Administrative Compliance

                    • Oversee clinical licensing and certification renewal processes.
                    • Coordinate licensure and certification activities across departments.
                    • Develop and maintain a centralized contract management system to ensure accessibility, tracking, and compliance with agreements.

                      • Governance & Committee Support

                      • Coordinate and/or support internal and Board-level committees (e.g., AHS Compliance, Corporate Compliance, Audit, HIPAA, Safety), including:
                        • Scheduling and logistics
                        • Agenda development
                        • Preparation and distribution of materials
                        • Documentation of meeting minutes
                        • Ensure preparation of agendas, meeting materials, reports, dashboards, and meeting minutes.
                        • Prepare and present compliance, audit, risk management, and regulatory updates to executive leadership and the Board of Directors.
                        • Evaluate program effectiveness and recommend continuous improvement initiatives. Prepare and present compliance-related reports and updates to executive leadership and the Board of Directors.

Supervisory Responsibilities:

  • Supervise Compliance Department staff.
  • Provide coaching, mentoring, performance management, and professional development.
  • Assign and monitor workload priorities and departmental goals.
  • Ensure confidentiality, professionalism, and accountability in all compliance activities.
  • Participate as a member of the management team in management team meetings, planning efforts, and organizational initiatives

    • General Agency/AHS Duties:

  • Fosters an environment that promotes trust and cooperation among clients and staff.
  • Enforces clinic policies and procedures, including maintenance of client confidentiality under HIPAA privacy rules, to ensure that the principles of AHS are implemented.
  • Plays an active role in planning organization-wide activities such as AHS general membership meetings, fundraisers, special clinic days and other events.
  • Participates in general membership meetings, fundraisers and other public events, as required.
  • Participates in outreach activities, agency advocacy, and serves on ad hoc committees, as requested.
  • Attends AHS staff retreats and Board of Directors meetings, as required.
  • Participates in agency-wide quality improvement program processes and performance improvement teams to ensure excellence in the quality of services provided across the agency.

    • Minimum Qualifications:

  • Bachelor’s degree in public health, public administration, public policy, business administration, or related field plus three to five years of progressively responsible administrative experience, or any equivalent combination of education and experience.
  • Demonstrated experience administering compliance programs within a healthcare organization, community health center, or FQHC environment.

    • Preferred Qualifications:

  • Minimum three (3) to five (5) years of progressively responsible experience in healthcare compliance, regulatory affairs, auditing, risk management, or healthcare administration.
  • Experience managing audits, accreditation reviews, regulatory reporting, and corrective action plans.
  • Familiarity with accreditation requirements.
  • Experience with accreditation and licensing surveys, i.e. Health Resources and Services Administration (HRSA) Operational Site Visit (OSV); The Joint Commission (TJC); Accreditation Association for Ambulatory Health Care (AACHC); Commission on Dental Accreditation (CODA)
  • Familiarity with compliance systems, such as Compliatric.
  • Prior supervisory experience.

    • Knowledge, Skills, and Abilities:

  • Strong knowledge of healthcare compliance laws, regulations, frameworks and standards – including Health Resources & Services Administration (HRSA), Health Insurance Portability and Accountability Act (HIPAA), Center for Medicare and Medicaid Services (CMS), Department of Health Care Services (DHCS), and Federal Tort Claims Act (FTCA).
  • Knowledge of risk management principles, compliance investigations, auditing, monitoring, and corrective action processes.
  • Demonstrated experience with managing audits, accreditation processes and compliance programs.
  • Ability to interpret laws, regulations, policies, contracts, and accreditation standards.
  • Strong analytical, organizational, project management, and problem-solving skills.
  • Excellent written, verbal, presentation, and interpersonal communication skills. Detail oriented.
  • Ability to effectively multi-task, manage multiple priorities and deadlines and work collaboratively across departments.
  • Work effectively in a high-stress and fast-moving environment.
  • Ability to handle sensitive and confidential information with discretion, judgement and professionalism.
  • Demonstrated commitment to cultural humility and serving diverse communities.
  • Demonstrated leadership skills with the ability to train and guide staff in the performance of their duties.
  • Knowledge and experience with cost and fund accounting.
  • Proficiency with Microsoft Office applications and compliance management systems.

    • Skills

    340BAudit And AccreditationCMSCompliatricData ReportingHIPAAHRSAMicrosoft OfficePolicy ManagementRisk Management

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