Description:
The Director of Compliance & Risk Management reports to the Chief Legal and Administrative Officer (CLAO) and serves as the operational leader of Salud Para La Gente’s compliance and risk management function. This role is responsible for the day-to-day management of compliance and risk operations across all clinic sites, directly supervising a compliance team including: the Quality & Compliance Analyst, the Compliance Analyst, and two Compliance Coordinators.
The Director leads implementation of Salud’s compliance program - including HRSA, FTCA, HIPAA, CDPH, CCAH, 340B, and other federal and state regulatory requirements - with a core focus on proactive risk identification and mitigation, potentially compensable event management, sentinel event response, incident reporting, credentialing and privileging, and organizational policies and protocols. This role requires regulatory expertise, practical operational judgment, and the ability to build a culture of safety, accountability, and nonpunitive error reporting across a dynamic, multi-site FQHC.
Duties and Responsibilities:
Compliance Program Oversight
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Lead day-to-day administration of Salud’s compliance program in accordance with HRSA guidance and all applicable federal, state, and local laws, regulations, and payer requirements; monitor regulatory developments and proactively assess organizational impact, providing timely guidance to the CLAO and operational leadership.
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Develop and maintain compliance work plans, monitoring calendars, and internal audit schedules; coordinate responses to government audits, health plan audits, subpoenas, and regulatory inquiries; prepare or oversee audit response materials and corrective action plans under the direction of the CLAO.
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Facilitate Salud’s HRSA FQHC operational site visit preparation; oversee the FTCA deeming application process and ongoing FTCA program compliance, including risk management plan maintenance, quarterly risk assessments, and annual reporting.
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Ensure compliance with Salud’s 340B program requirements in coordination with financial and clinical operations leadership.
Risk Management & Patient Safety
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Proactively evaluate areas of organizational risk based on internal assessment and external benchmarking; implement strategies and policies that promote patient, staff, and organizational safety across all sites.
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Direct the investigation of all potentially compensable events, evaluating each for severity, frequency, and probability of financial loss; promptly escalate potential FTCA or other claims and adverse events to the CLAO appropriate committees, and leadership as required.
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Lead root cause analysis (RCA) or failure mode and effects analysis (FMEA) reviews of serious occurrences; respond to sentinel events and provide guidance to leadership on management, reporting, and regulatory notification obligations; disseminate lessons learned and ensure follow-through on process improvement plans.
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Maintain and update the organizational risk dashboard; conduct periodic risk assessments and present findings with recommended action plans to the CLAO and Risk Management Committee.
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Ensure maximum protection from discovery of all claims materials; coordinate claims investigation and legal defense processes with the CLAO and outside legal counsel; promote a culture of nonpunitive error reporting throughout the organization.
Safety Program & Emergency Management
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Serve as Safety Officer; co-lead the Safety and Security Committee; oversee safety walkthroughs across all clinic sites, documenting findings and ensuring timely resolution of identified risks.
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Coordinate Salud’s emergency management program; ensure the Emergency Operations Plan is current, site-specific, and supported by regular staff training on response and recovery procedures at all sites.
Incident & Grievance Management
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Oversee Salud’s incident and grievance system, ensuring timely intake, triage, investigation, documentation, and resolution of all reported incidents and patient grievances across all sites.
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Direct the compliance team in incident and grievance trend tracking, root-cause analysis coordination, and corrective action documentation; maintain the incident reporting system and ensure staff access and training across all sites.
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Report incident and grievance trends - including frequency, severity, and risk patterns - to the Risk Management Committee, Quality Committees, and CLAO as needed and as appropriate.
HIPAA & Privacy Compliance
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Oversee Salud’s HIPAA Privacy and Security programs, including policy management and workforce training.
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Lead HIPAA breach investigations under the direction of the CLAO; assess breach severity, coordinate required notifications, and maintain documentation in accordance with federal breach notification requirements.
Credentialing, Privileging & Licensing
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Provide operational oversight of compliance team members responsible for provider and clinical staff credentialing and privileging; ensure processes comply with HRSA, FTCA, and health plan requirements with timely re-credentialing cycles for all providers and applicable clinical staff.
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Oversee management of all organizational and clinic licenses across all Salud sites; ensure timely renewals and complete records.
Policies, Protocols & Training
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Oversee Salud’s policy and procedure program, including policy review cycles, timely updates in collaboration with department leads, and Board of Directors approval processes.
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Develop and deliver - or oversee delivery of - compliance and risk management training for staff, managers, and contractors across all sites; ensure content reflects current HRSA guidance.
Committee Leadership
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Lead and facilitate the Risk Management Committee and Safety & Security Committee; develop agendas, compile minutes, track action items, and report to the CLAO; support Board QAQI Committee materials preparation in partnership with the CLAO.
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Participate in the Quality Committees and other organizational committees as assigned.
Staff Supervision & Development
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Directly supervise four Compliance team members: Quality & Compliance Analyst, Compliance Analyst, and two Compliance Coordinators; provide clear performance expectations, regular feedback, performance evaluations, and professional development support for each direct report; hold team members accountable to established standards, documentation requirements, and regulatory timelines.
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Integrate the work of analysts and coordinators to ensure cohesive compliance operations, particularly where incident investigations, policy updates, training needs, and credentialing issues intersect.
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Foster a team culture of integrity, accountability, continuous learning, and collaborative problem-solving; support onboarding an mentorship of developing staff.
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Perform other related duties as assigned by the Chief Legal and Administrative Officer.
Requirements:
MINIMUM QUALIFICATIONS:
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Bachelor’s degree in healthcare administration, public health, law, business, or a related field required.
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Minimum five (5) years of progressive experience in healthcare compliance, risk management, or a closely related field; experience in a federally qualified health center, community health center, county health agency, or similarly complex regulated healthcare environment strongly preferred.
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Minimum two (2) years of supervisory or team lead experience, with demonstrated ability to manage staff across multiple functional areas.
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Experience with potentially compensable event investigation, root-cause analysis, and claims management coordination.
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Experience managing or participating in credentialing and privileging processes.
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Excellent written, oral, and interpersonal communication skills; ability to present complex regulatory and risk information clearly to diverse audiences including clinical staff, executives, and governing boards.
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Highly organized and detail-oriented; demonstrated ability to manage multiple priorities simultaneously across a multi-site organization.
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Proficiency with Microsoft Office Suite.
PREFERRED QUALIFICATIONS:
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Master’s degree in a related field.
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Bilingual in Spanish and English.
