POSITION SUMMARY: The Director of Compliance is responsible for leading, coordinating, and monitoring the organization’s compliance, regulatory readiness, privacy, policy management, and enterprise risk management activities. Reporting to Chief Clinical Officer, the Director provides organization-wide leadership in establishing and maintaining systems that promote regulatory compliance, operational accountability, quality improvement, and risk reduction. The Director serves as the organization’s designated HIPAA Privacy Officer, leads the organizational Policy Committee, coordinates activities related to The Joint Commission accreditation, and oversees a structured compliance and risk management process across all programs and administrative departments. The position conducts routine audits, coordinates corrective actions, and reports compliance performance, emerging risks, and recommendations to senior leadership. |
Accountable and responsible for the following results: 1. Organizational Compliance Leadership - Develop, implement, and maintain an organization-wide compliance program consistent with applicable federal and Connecticut laws, regulations, contractual obligations, accreditation standards, and organizational policies.
- Establish an annual compliance work plan identifying priorities, monitoring activities, regulatory requirements, and organizational risk areas.
- Provide consultation to program and department leaders on compliance expectations; monitor regulatory changes and coordinate organizational responses.
- Promote ethical conduct and maintain processes to receive, evaluate, investigate, document, and resolve compliance concerns.
- Coordinate significant compliance matters with senior leadership, legal counsel, and other designated personnel.
2. Joint Commission Accreditation and Regulatory Readiness - Coordinate organizational activities related to The Joint Commission accreditation and continuous survey readiness.
- Monitor applicable standards, communicate changes, and work with leaders to close compliance gaps.
- Coordinate mock surveys, tracer activities, document reviews, and readiness assessments.
- Track accreditation findings, corrective actions, and evidence of sustained compliance; support survey preparation and required follow-up submissions.
3. HIPAA Privacy Officer - Serve as designated HIPAA Privacy Officer and oversee implementation of HIPAA Privacy Rule requirements and applicable state confidentiality requirements.
- Maintain privacy policies; respond to privacy questions, complaints, and reported concerns.
- Coordinate investigation of suspected unauthorized uses or disclosures of protected health information and breach assessments, notifications, and corrective actions with appropriate leadership and counsel.
- Oversee applicable patient privacy rights processes, including access, amendment, restrictions, and accounting of disclosures.
- Coordinate privacy education and training; monitor privacy practices and maintain investigation documentation.
- Collaborate with the designated HIPAA Security Officer and IT leadership on privacy and information security risks.
4. Regulatory Reviews, Investigations, and Corrective Actions - Coordinate compliance-related responses to licensing, accreditation, contractual, and regulatory reviews.
- Support external audits, inspections, and investigations; track findings, plans of correction, deadlines, and evidence.
- Review corrective action plans, monitor implementation, and verify sustained effectiveness.
- Coordinate assigned internal compliance investigations with confidentiality and appropriate documentation.
- Refer legal, clinical, personnel, or executive decisions to the appropriate authority.
- Policy Committee Leadership and Policy Governance
- Chair the organizational Policy Committee and maintain a structured policy development, review, approval, revision, and retirement process.
- Maintain a centralized policy inventory, review calendar, version controls, and approval records.
- Coordinate multidisciplinary policy reviews and ensure clear owners, effective dates, and approval authorities.
- Monitor overdue reviews, coordinate communication and implementation, and report policy status to senior leadership.
5. Enterprise Compliance and Risk Management - Lead an organization-wide process to identify, assess, document, monitor, and mitigate compliance and operational risks.
- Establish and maintain a risk register with risk ratings, assigned owners, mitigation plans, deadlines, and follow-up.
- Facilitate periodic risk assessments across clinical, documentation, privacy, billing, staffing, regulatory, and administrative functions.
- Coordinate with quality, patient safety, HR, finance, and operations leaders; escalate significant or unresolved risks.
- Monitor incident trends and the effectiveness of risk mitigation strategies.
6. Compliance Auditing and Monitoring - Develop and execute an annual risk-based internal audit schedule across programs and administrative departments.
- Review compliance with licensing, accreditation, contractual, organizational policy, and relevant federal and state requirements.
- Audit areas such as clinical documentation, authorizations, privacy, staff credentials, regulatory records, and operational controls.
- Coordinate billing and reimbursement compliance audits with finance and revenue cycle personnel.
- Develop standardized audit tools and reports identifying findings, risk levels, recommendations, and corrective actions.
- Track corrective actions and conduct follow-up audits to verify sustained improvement; identify cross-program trends.
7. Compliance Reporting and Senior Leadership Accountability - Prepare and present routine compliance reports and an organizational compliance dashboard to senior management.
- Report accreditation readiness, privacy incidents, audit findings, corrective actions, policy review completion, and risk trends.
- Escalate critical concerns promptly and identify vulnerabilities requiring executive decisions or resources.
- Support reporting to the governing body or designated board committee as requested or required.
- Monitor compliance indicators and progress toward organizational goals.
8. Compliance Education and Organizational Support - Identify compliance training needs and coordinate education on HIPAA, regulatory requirements, policies, ethics, and risk.
- Partner with Human Resources and program leaders to integrate compliance expectations into onboarding and ongoing development.
- Coach leaders on compliance monitoring and corrective action responsibilities.
- Evaluate training effectiveness using audit results, monitoring, and staff feedback.
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MINIMUM QUALIFICATIONS- EDUCATION/EXPERIANCE | - Bachelor’s degree in healthcare administration, public health, human services, business administration, nursing, social work, or a related field required.
- Master’s degree in a relevant discipline preferred.
- At least five years of progressively responsible experience in healthcare, behavioral health, human services, compliance, quality assurance, risk management, or a related field.
- Experience conducting audits, interpreting regulations, coordinating corrective actions, and working with senior leaders.
- Joint Commission and multi-program behavioral health experience preferred.
- Familiarity with Connecticut healthcare and human services requirements preferred.
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REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES
| - Knowledge of healthcare compliance, HIPAA privacy, confidentiality, accreditation, licensing, and contractual oversight.
- Ability to develop risk-based audits, interpret requirements, and translate them into practical procedures.
- Strong analytical, investigative, problem-solving, written communication, and executive reporting skills.
- Ability to develop dashboards, monitor indicators, and manage multiple organizational priorities.
- Professional independence, confidentiality, sound judgment, and collaborative leadership.
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