Agency Compliance Coordinator

JOB SUMMARYThe Agency Compliance Coordinator is a mid-management position responsible for coordinating and monitoringcompliance across all Hope Haven programs and departments. This role ensures the agency meets the requirements ofCARF accreditation, NC DHHS licensure under 10A NCAC 27G, NC Medicaid clinical coverage policies, LME/MCOcontracts, and federal privacy laws for every service the agency provides, including its residential treatment services and theoutpatient services it will add as it grows. The coordinator serves as the agency’s central resource on compliance,communicating with staff at every level and in every department, and reports all compliance activities, findings, andconcerns to the Director of Admission and Regulatory Compliance to keep Hope Haven survey -ready year-round.ESSENTIAL DUTIES AND RESPONSIBILITIES:Agency Compliance Program• Coordinate the agency’s compliance program and annual compliance work plan under the direction of the Directorof Admission and Regulatory Compliance, including an annual risk assessment of all programs and departments.• Coordinate the Compliance and Quality Committee, including agendas, minutes, and tracking of action items.• Provide monthly compliance reports to the Director and prepare quarterly summaries for the Director to share withsenior leadership and the Board.• Maintain a confidential process for staff to report compliance concerns and report all concerns promptly to theDirector.Service Compliance• Monitor compliance with the clinical coverage policy, licensure rules, and documentation standards for eachresidential and outpatient service the agency offers.• Verify service requirements are met, such as service orders, assessments and their timeframes, Person -CenteredPlans, minimum service hours, staffing ratios, and required documentation.• Support readiness for new services by coordinating licensure applications, LME/MCO contracting and credentialingrequirements, policy development, and required staff training before launch, and report readiness status to theDirector.Accreditation and Licensure• Maintain CARF accreditation by monitoring conformance to standards, coordinating the Annual Conformance toQuality Report, and preparing for resurvey.• Coordinate preparation for DHHS licensure surveys, complaint investigations, and LME/MCO monitoring reviews,and draft plans of correction with department leaders for the Director’s review by required deadlines.• Monitor incident reporting through the state incident reporting system, ensuring incidents are reported, reviewed,and addressed within required timeframes.• Track changes in state and federal regulations, CARF standards, and Medicaid bulletins, and report their impact tothe Director.Medicaid, Privacy, and Records Compliance• Conduct monthly documentation audits and pre-billing and post-payment audits of Medicaid and state-fundedservices using agency audit tools, and report findings to the Director.• Track corrective action plans to completion and report any potential overpayments to the Director so they can berepaid within federally required timeframes.• Complete monthly exclusion screening of staff, contractors, and vendors against federal and state exclusion lists.• Coordinate compliance with HIPAA and 42 CFR Part 2, including consent forms, release of information, and thenotice prohibiting redisclosure.• Oversee records management, records requests, and retention for active and discharged client files.• Report potential privacy breaches to the Director immediately and assist with investigations and requirednotifications.• Adhere to the Resident’s Rights Policy, the agency Code of Ethics, and professional and ethical boundaries.• Perform other duties as assigned by the Director.Communication, Training, and Collaboration• Serve as the agency’s primary internal point of contact for compliance with questions, and communicate regularlywith staff in all departments, including clinical, admissions, residential, medical, family programs, workforcedevelopment, business, finance, HR, operations, and food services.• Share regular compliance updates with staff, such as a monthly compliance brief approved by the Director, andattend department meetings as needed.• Coordinate annual compliance, privacy, and ethics training, and track staff completion of training required by eachclinical coverage policy.• Track staff licenses, certifications, and credentials, and notify supervisors and the Director before expirations.• Maintain the agency’s Policy and Procedure Manual, coordinate annual reviews, and ensure staff have access tocurrent policies.• Supervise compliance or records staff as assigned by the Director.Physical Demands• May sit, stand, and walk for extended periods throughout the workday.• Frequently uses a computer and standard office equipment.• Occasionally lifts or moves materials weighing up to 20 pounds.Work EnvironmentWork is performed in a professional work environment with regular interaction with employees, clients, and otherstakeholders.Pre-Employment RequirementsAll offers of employment are contingent upon successful completion of Hope Haven’s pre -employment screeningrequirements, which may include background verification and other screening requirements applicable to the position andconsistent with applicable law.This position may require operating a Hope Haven vehicle or transporting activity materials on an occasional or as-neededbasis. When assigned driving duties, the employee must maintain a valid driver’s license and be insurable under HopeHaven’s automobile insurance policy.DisclaimerThis job description describes the general nature and level of work performed by employees assigned to this position. It isnot intended to be an exhaustive list of all duties, responsibilities, or qualifications. Duties and responsibilities maychange based on organizational needs.Minimum Qualification Requirements• Bachelor’s degree in human services, Health Care Administration, Business Administration, or a related fieldrequired.• Minimum of three (3) years of experience in compliance, quality assurance, or accreditation in a behavioral health,substance use disorder, or licensed health care setting.• Experience with CARF accreditation standards and survey preparation.• Working knowledge of NC Medicaid clinical coverage policies, LME/MCO requirements, and 10A NCAC 27Glicensure rules.• Knowledge of HIPAA and 42 CFR Part 2 confidentiality requirements.• Experience with electronic health records; experience with KIPU preferred.• Qualified Professional (QP) status or Certification in Healthcare Compliance (CHC) preferred.• Strong communication and relationship-building skills, with the ability to explain requirements clearly to staff at alllevels.• Strong organizational and project management skills, with the ability to manage multiple deadlines.• Knowledge of the dynamics of the disease of addiction and its treatment.• Must have a valid driver’s license and be insured by Hope Haven’s carrier. #J-18808-Ljbffr Hope Haven Inc.