Compliance Manager
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AI Summary
The Compliance Manager oversees and coordinates the organization's compliance program to ensure adherence to licensing requirements and CARF accreditation standards. They are responsible for monitoring policies, conducting internal audits, managing staff training, and preparing the organization for regulatory inspections.
Benefits:
- Flexible schedule
- Opportunity for advancement
Position Summary
The Compliance Manager is responsible for overseeing and coordinating the organization’s compliance program to ensure ongoing adherence to all applicable licensing requirements, CARF accreditation standards, organizational policies and procedures, and other applicable regulatory requirements.
This position will help the organization remain organized, audit-ready, and proactive in meeting compliance expectations. The Compliance & Accreditation Manager will develop and maintain systems for tracking licensing and accreditation requirements, coordinate staff training and documentation, monitor compliance with policies and procedures, and work closely with leadership and staff to identify and address areas of risk or non-compliance.
The ideal candidate is highly organized, detail-oriented, proactive, and comfortable managing multiple compliance requirements and deadlines. Experience working with CARF accreditation and/or healthcare, behavioral health, human services, or other applicable licensing and regulatory requirements is strongly preferred.
Key Responsibilities
Licensing & Regulatory Compliance
- Monitor and maintain compliance with all applicable state, local, and regulatory licensing requirements.
- Maintain an organized system for tracking licenses, certifications, renewals, inspections, required documentation, and compliance deadlines.
- Ensure required documentation is complete, current, accurate, and readily available for regulatory review.
- Stay informed of changes to licensing requirements, regulations, and applicable standards and communicate relevant changes to leadership and staff.
- Coordinate preparation for licensing inspections, surveys, audits, and other regulatory reviews.
- Identify potential compliance gaps and work with leadership to develop and implement corrective action plans.
CARF Accreditation
- Coordinate the organization’s ongoing readiness for CARF accreditation and reaccreditation.
- Maintain organized documentation demonstrating compliance with applicable CARF standards.
- Monitor CARF requirements and help ensure policies, procedures, practices, documentation, and staff training remain aligned with applicable standards.
- Coordinate preparation for CARF surveys and assist with survey readiness activities.
- Track findings, recommendations, and corrective actions resulting from accreditation surveys or internal reviews.
- Partner with leadership and department managers to address identified deficiencies and maintain continuous accreditation readiness.
Staff Training & Competency Compliance
- Develop, organize, and maintain a comprehensive staff training and compliance calendar.
- Ensure employees complete all required initial, annual, recurring, and role-specific training within required timeframes.
- Track staff training completion and maintain accurate training records.
- Coordinate training related to licensing requirements, CARF standards, organizational policies and procedures, safety, documentation, ethics, and other regulatory requirements.
- Identify upcoming training requirements and communicate deadlines to staff and supervisors.
- Work with leadership and department managers to address overdue or incomplete training.
- Maintain documentation demonstrating staff competency and compliance with required training standards.
Policies & Procedures
- Monitor compliance with organizational policies and procedures.
- Maintain an organized system for reviewing, updating, approving, distributing, and documenting policies and procedures.
- Help ensure policies and procedures remain consistent with current licensing requirements, CARF standards, and applicable regulations.
- Track required policy reviews and revisions.
- Assist leadership with developing new policies and procedures when compliance requirements change.
- Help ensure staff are informed of and trained on significant policy and procedure changes.
Compliance Monitoring & Quality Improvement
- Conduct or coordinate internal compliance audits and reviews.
- Monitor documentation and operational practices for compliance with regulatory and accreditation requirements.
- Maintain compliance dashboards, trackers, reports, and other tools to provide leadership with visibility into organizational compliance.
- Identify trends, recurring issues, and areas of risk.
- Assist with the development and monitoring of corrective action and performance improvement plans.
- Promote a culture of continuous quality improvement and regulatory compliance throughout the organization.
Collaboration & Communication
- Work closely with executive leadership, clinical/operational leadership, HR, supervisors, and other departments to support organizational compliance.
- Provide leadership with regular updates regarding compliance status, upcoming deadlines, training completion, audit findings, and identified risks.
- Educate staff regarding compliance expectations and the importance of maintaining regulatory and accreditation standards.
- Serve as a central resource for questions related to licensing, accreditation, policies, procedures, and compliance requirements.
Qualifications
Required
- Strong organizational and project-management skills.
- Excellent attention to detail and follow-through.
- Ability to manage multiple deadlines, requirements, and projects simultaneously.
- Strong written and verbal communication skills.
- Ability to maintain confidential and sensitive information..
Preferred
- Experience with accreditation standards and survey preparation.
- Experience with state or local licensing requirements in a healthcare, behavioral health, substance use, mental health, human services, or similar regulated environment.
- Experience coordinating regulatory inspections, audits, accreditation surveys, or corrective action plans.
- Experience developing and managing employee training and competency programs.
- Experience with compliance auditing, quality assurance, or performance improvement.
- Familiarity with electronic health records and compliance/document management systems.
Key Success Measures
Success in this position will be demonstrated by:
- Maintaining continuous readiness for licensing inspections and CARF surveys.
- Timely completion and renewal of all required licenses, certifications, and regulatory requirements.
- High completion rates for required employee training and competencies.
- Accurate and organized compliance documentation.
- Consistent adherence to organizational policies and procedures.
- Timely identification and resolution of compliance gaps.
- Effective tracking and completion of corrective action plans.
- Clear, consistent reporting to leadership regarding organizational compliance status.
- A proactive organizational culture focused on compliance, quality, and continuous improvement.
This is a remote position.
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