Compliance Manager

Compliance Manager

ABERDEEN, MD

Key Point Health Services is a leading nonprofit agency serving people with behavioral healthcare needs in the Greater Baltimore area. We provide comprehensive community-based services that help people thrive while realizing and choosing their goals. We provide opportunities, support and integration within our community. Among the programs and services, we provide are Outpatient Mental Health Centers, Adult and Child Psychiatric Rehabilitation Programs, School-Based Therapy, Community Outreach, and Residential Services.

We are currently looking for a Compliance Manager to join our Aberdeen team.

Summary of Responsibilities:

CARF Accreditation

• Lead all organizational CARF accreditation activities.
• Develop and maintain CARF readiness plans and accreditation timelines.
• Monitor compliance with CARF standards throughout the accreditation cycle.
• Coordinate mock surveys and internal readiness assessments.
• Maintain accreditation evidence files and documentation.
• Provide ongoing education regarding CARF standards to staff and leadership.
• Coordinate survey logistics and organizational readiness activities.
• Monitor implementation of corrective action plans following surveys or audits.
• Support departments in integrating CARF standards into daily operations.

Behavioral Health Regulatory Compliance

• Monitor compliance with Maryland COMAR regulations, CMS requirements, Medicaid regulations, HIPAA, 42 CFR Part 2, OSHA standards, and other applicable behavioral health regulations.
• Develop and maintain organizational compliance policies and procedures.
• Oversight of the collection of data and analysis of trends related to medical record compliance
• Conduct ongoing compliance monitoring activities.
• Investigate potential compliance concerns and recommend corrective actions.
• Coordinate regulatory surveys and licensing reviews.

Pharmacy Compliance

• Coordinate organizational compliance with applicable pharmacy regulations.
• Monitor compliance (either directly or through oversight of staff) with:
• Maryland Board of Pharmacy requirements
• DEA regulations
• Controlled substance requirements
• Medication storage and security standards
• Medication disposal procedures
• Provide oversight to the Medication Auditor
• Review medication-related incidents and identify trends.
• Recommend improvements to medication management practices.

Corporate Compliance

• Maintain the organization's compliance program.
• Conduct annual compliance risk assessments.
• Develop and monitor the annual compliance work plan.
• Coordinate investigations related to compliance concerns.
• Monitor OIG, SAM, and state exclusion lists.
• Coordinate annual compliance education.
• Maintain confidential reporting mechanisms.
• Track compliance activities and recommend corrective actions.

Quality Improvement

• Collaborate with Quality Improvement initiatives.
• Identify compliance trends through data analysis.
• Recommend process improvements.
• Participate in performance improvement projects.
• Support organizational KPI reporting.
• Assist with risk management activities.

Education & Training

• Develop and coordinate annual compliance training.
• Provide education related to:
• CARF standards
• HIPAA
• Fraud, Waste and Abuse
• Documentation standards
• Medication compliance
• Ethics
• Corporate Compliance
• Conduct new employee orientation training related to compliance.
• Develop educational materials and maintain training records.

Incident Management

• Review reportable incidents for compliance implications.
• Monitor incident trends.
• Ensure required regulatory reporting is completed.
• Oversight of Safety Committee.
• Lead Root Cause Analyses as appropriate.
• Track corrective actions to completion.

Policy Management

• Coordinate organizational policy review and revision schedules.
• Ensure policies remain compliant with regulatory requirements.
• Assist departments with policy development and revisions.
• Maintain policy documentation and version control.

Supervision and Coordination of Responsibilities

The Compliance Manager is responsible for reporting directly to the Chief Operations Officer. The Compliance Manager supervises the Streamline Medication Training Auditor position. The Compliance Manager collaborates with all other disciplines through interdisciplinary teamwork and assigned responsibilities.

The Compliance Manager adheres to the ethics of their respective profession.

Desirable Minimum Qualifications

Knowledge, Skills, and Abilities:

Demonstrated knowledge of behavioral health regulations, including Maryland COMAR regulations, Medicaid requirements, HIPAA, and applicable federal and state regulatory standards.

• Experience supporting or leading accreditation activities (CARF, Joint Commission, or similar accrediting body).
• Experience conducting compliance audits, monitoring activities, and developing corrective action plans.
• Strong analytical, organizational, and project management skills.
• Excellent written, verbal, and presentation communication skills.
• Proficiency with Microsoft Office applications and electronic health record systems.

Education and Experience:

• Bachelor's degree in Healthcare Administration, Public Health, Nursing, Social Work, Business Administration, Criminal Justice, or another related field.
• Minimum of three (3) years of progressively responsible experience in healthcare compliance, accreditation, quality improvement, risk management, or regulatory oversight within a behavioral health or healthcare organization.

Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to stand; walk; use hands to handle objects, tools, or controls; reach with hands and arms; and talk or hear. The employee frequently is required to sit, climb, ascend and descend stairs, balance, taste, and smell. The employee is required to stoop, kneel, crouch, or crawl. The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception, and the ability to adjust focus.

Work Environment

The Compliance Manager works in an office setting, The Compliance Manager is not expected to be exposed to unusual levels of heat, cold, light or noise. The position may require repetitive use of computer, keyboard, mouse and some audio-visual equipment.

It is the policy of Key Point Health Services to provide equal employment opportunity (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law.