Compliance Specialist

Description

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The Compliance Specialist supports the day-to-day operation of the Valley View Health Centers Compliance Program under the direction of the Director of Continuous Quality Improvement. This role monitors compliance activities, maintains organized documentation, coordinates information for audits and regulatory reviews, tracks training and corrective actions, and assists with policy management. The Compliance Specialist also supports accreditation, risk management, safety, and emergency preparedness activities while working closely with health center leaders and staff to promote consistent practices, identify concerns, and ensure required information is complete and readily available for review.
Health Center Compliance Monitoring and Support

Estimated Effort: 60%

• Support implementation and maintenance of the Valley View Health Centers Compliance Program under the direction of the Director of Continuous Quality Improvement.
• Maintain the health center compliance calendar, work plan, tracking tools, and organized electronic and paper records.
• Monitor updates to applicable federal and state requirements, including:
  • HRSA Health Center Program
  • FTCA
  • HIPAA
  • OSHA
  • CARF
  • Payer requirements
  • Contractual requirements
• Provide summaries of applicable regulatory updates to the Director.
• Coordinate collection of policies, records, reports, and other evidence required for audits, assessments, applications, renewals, and regulatory reviews.
• Perform routine compliance audits, record reviews, and monitoring activities using approved tools and criteria.
• Document audit results and promptly communicate identified concerns, trends, or potential noncompliance to the Director.
• Maintain corrective action trackers and follow up with assigned departments to obtain evidence of completion by established deadlines.
• Assist with the review, formatting, routing, approval tracking, distribution, and scheduled revision of health center policies and procedures.
• Maintain current policy inventories, approval records, revision histories, and staff acknowledgment records.
• Prepare draft compliance reports, dashboards, presentations, meeting materials, and summaries for leadership and Board review.
• Provide administrative support for compliance, quality, and risk-related meetings, including agendas, minutes, supporting documentation, and action-item tracking.
• Assign and track required compliance training, send completion reminders, and maintain accurate training records.
• Assist with compliance education and new employee orientation using approved materials.
• Perform exclusion, sanction, license, and eligibility screenings for assigned employees, contractors, providers, Board members, or vendors and promptly escalate potential matches.
• Receive and document routine compliance questions or concerns and promptly route them to the Director of Continuous Quality Improvement.
• Support authorized compliance reviews and investigations by gathering documentation, preparing timelines, organizing evidence, and completing assigned tasks.
• Coordinate with Privacy, Security, Human Resources, Information Technology, and operational leaders when compliance concerns involve confidentiality, system access, workforce requirements, or organizational policies.
• Review selected workflows, forms, and records for adherence to approved policies and regulatory requirements and submit observations and recommendations to the Director.
• Maintain audit-ready compliance files so requested documentation can be located and produced accurately and timely.
• Provide professional technical assistance to staff regarding established compliance processes and escalate matters requiring interpretation or leadership decisions.
• Promote a culture of integrity, accountability, confidentiality, non-retaliation, and continuous improvement throughout Valley View Health Centers.

Accreditation, Risk, Safety, and Emergency Preparedness Support

Estimated Effort: 30%

• Support preparation of HRSA, FTCA, CARF, accreditation, grant, payer, and other required submissions by organizing evidence and preparing draft materials for review.
• Maintain regulatory and accreditation requirement lists, submission calendars, document inventories, and readiness files.
• Coordinate requested documentation and logistical support for external audits, assessments, inspections, and site visits.
• Assist with quarterly risk assessments, annual risk management reporting, and related follow-up activities.
• Compile and organize incident, complaint, grievance, near-miss, safety, and risk data for trend review and reporting.
• Participate in facility walkthroughs and approved monitoring activities related to:
  • OSHA
  • HIPAA
  • Safety
  • Emergency preparedness
  • Environment of care
• Document findings from walkthroughs and reviews and track assigned corrective actions through completion.
• Assist with maintaining OSHA, safety, accreditation, risk management, and emergency preparedness manuals, logs, and supporting records.
• Coordinate and document code drills, emergency exercises, and after-action activities under the direction of health center leadership.
• Assist with updates to the Emergency Response Plan, Risk Management Plan, Training Plan, and related procedures.
• Track completion of required risk, safety, emergency preparedness, and accreditation training and maintain supporting documentation.
• Attend meetings, conferences, and training sessions related to assigned duties and share relevant information with the Director and appropriate staff.

Service and Other Responsibilities

Estimated Effort: 10%

• Serve on Valley View Health Centers and CAC teams or committees as assigned.
• Assist with special projects, data collection, document preparation, and other compliance-related activities as directed.
• Attend meetings, conferences, and trainings as needed.
• Complete routine travel among Valley View Health Centers locations when required.
• Perform other duties necessary to support the organization's mission, vision, values, and compliance objectives.

Minimum Requirements

Education:
Associate degree in Healthcare Administration, Business Administration, Compliance, Health Information, Nursing, or a related field. An equivalent combination of relevant education and experience may be accepted in lieu of the degree requirement.

Job-Related Experience:
Minimum of one (1) year of experience in healthcare administration, compliance, quality improvement, risk management, accreditation, auditing, or a related field preferred. Experience in an FQHC, nonprofit, or ambulatory healthcare setting is preferred.

People Management Experience:
No people management experience required. This position has no direct supervisory responsibilities.

Applications:

• Strong working knowledge of Microsoft Office.
• Ability to learn electronic systems used by the organization, including:
  • Electronic health record systems
  • Training systems
  • Policy management systems
  • Reporting systems
  • Exclusion-screening systems
  • Document-storage systems

Preferred Qualifications

• Knowledge of HIPAA requirements.
• Knowledge of HRSA Health Center Program requirements.
• Knowledge of FTCA requirements.
• Knowledge of OSHA requirements.
• Knowledge of CARF standards.
• Experience with healthcare compliance auditing.
• Experience with policy management.
• Experience with training administration.
• Healthcare compliance or related certification preferred but not required.

Working Conditions

This position operates primarily in a climate-controlled office environment, with some work performed in clinical settings. The position regularly requires sitting, reaching, handling objects or controls, speaking, and hearing. Occasional standing, walking, stooping, kneeling, crouching, or crawling may be required. The employee must regularly lift or move up to 10 pounds and occasionally lift or move up to 25 pounds. Routine travel among Valley View Health Centers locations may be required.

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