PRIMARY DUTIES and RESPONSIBILITIES SUMMARY:
The Compliance & Risk Management Officer is responsible for leading and overseeing a comprehensive compliance and risk management program across a multi-site Federally Qualified Health Center (FQHC) delivering integrated medical, dental, behavioral health, lab and pharmacy services.
This position ensures compliance with federal (HRSA/FQHC, FTCA), state (North Carolina), and accreditation (Joint Commission) requirements while maintaining adherence to HIPAA, OSHA, infection control standards, and pharmacy regulatory requirements. The role also leads enterprise-wide risk management, incident investigation, and malpractice prevention efforts to ensure high-quality, safe patient care across all service lines and locations.
Service Line Compliance Integration: Ensure regulatory compliance across all clinical services:
Medical & Behavioral Health
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Ensure compliance with clinical quality standards, patient safety protocols, and behavioral health privacy requirements.
Dental Services
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Monitor compliance with infection control, sterilization protocols, and dental-specific regulatory standards.
Pharmacy Services
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Ensure compliance with state pharmacy board regulations, 340B program requirements, medication storage, dispensing, and controlled substances handling.
Regulatory & Program Compliance
- Develop, implement, and maintain an organization-wide compliance program aligned with HRSA/FQHC requirements, FTCA standards, and North Carolina regulations.
- Ensure ongoing compliance with Joint Commission accreditation standards, including survey readiness and follow-up on recommendations.
- Monitor regulatory updates and ensure organizational policies reflect current laws and best practices.
- Serve as a primary liaison during external audits, accreditation reviews, and regulatory inspections.
HIPAA & Privacy Compliance
- Serve as or support the HIPAA Privacy and Security Officer.
- Ensure compliance with HIPAA Privacy, Security, and Breach Notification Rules.
- Conduct regular privacy and security risk assessments.
- Investigate privacy incidents and breaches, ensuring proper reporting and mitigation.
Works with Infection Control & Clinical Compliance staff to ensure compliance
OSHA & Workplace Safety
- Ensure compliance with Occupational Safety and Health Administration (OSHA) standards.
- Oversee workplace safety programs, including training on bloodborne pathogens, hazard communication, and employee safety.
- Conduct safety inspections and implement corrective measures to mitigate workplace risks.
Risk Management & Incident Investigation
- Lead and manage the organization’s risk management program.
- Review, investigate, and analyze incident reports, adverse events, and near-miss occurrences.
- Identify trends and implement strategies to reduce risk and prevent future incidents.
- Conduct root cause analyses and recommend corrective actions.
- Collaborate with leadership and legal counsel to mitigate risks associated with malpractice exposure.
- Ensure proper documentation and reporting of incidents in accordance with regulatory requirements.
Policy Development & Training
- Develop, review, and update organizational policies and procedures to ensure regulatory compliance.
- Provide ongoing compliance and risk management training to staff and leadership.
- Promote a culture of ethical conduct, accountability, and patient Monitoring, Auditing & Reporting
- Conduct internal audits to assess compliance with regulatory and accreditation standards.
- Track and report compliance metrics, risks, and corrective actions to executive leadership and the Board.
- Maintain records and documentation for all compliance-related activities.
- safety.
Leadership & Collaboration
- Serve as a strategic advisor to executive leadership on compliance and risk matters.
- Collaborate with clinical, administrative, and operational departments to integrate compliance into daily workflows.
- Support quality improvement initiatives aligned with regulatory and accreditation requirements.
Each staff member is a member of the Patient Centered Medical Home model and you are required to work as part of a team to provide high-quality, patient-focused care. Your role is to help ensure patients have timely access to services, support coordinated care by communicating effectively with team members and patients, and contributing to quality improvement efforts. Your commitment to respectful, compassionate service and teamwork is required to help us meet PCMH standards, improve patient outcomes, and maintain a supportive care environment.
Corporate Compliance: It is an essential job element that everyone be compliant with the full law and fully cooperate with the compliance program without fear of retaliations from the organization.
SUPERVISORY RESPONSIBILITIES: Volunteers
ADMINISTRATIVE RESPONSIBILITIES: None
QUALIFICATION REQUIREMENTS:
Education
- Bachelor’s degree in Healthcare Administration, Nursing, Public Health, or related field required
Experience
- Minimum 3–5 years of healthcare compliance and/or risk management experience, preferably in an FQHC or community health setting
- Experience with Joint Commission accreditation, HRSA compliance, and FTCA requirements strongly preferred
- Master’s degree preferred
Certifications (Preferred)
- Certified in Healthcare Compliance (CHC)
- Certified Professional in Healthcare Risk Management (CPHRM)
- Certified Professional in Healthcare Quality (CPHQ) (optional)
Key Performance Indicators (KPIs)
- Successful Joint Commission accreditation outcomes across all sites
- Full compliance with HRSA program requirements and FTCA deeming status
- Reduction in incident rates and malpractice risk exposure
- Timely completion and resolution of incident investigations
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High compliance scores in internal and external audits
- Staff training completion rates across all service lines
- Zero or minimized HIPAA breaches and OSHA violations
INTERPERSONAL SKILLS: Excellent interpersonal and customer service skills. Teamwork and communication skills are essential. Treat all patients, co-workers, and managers with courtesy and respect.
MENTAL ABILITIES: Cognitive reasoning. Clear thinking in high-pressure situations. Ability to prioritize and withstand pressure of continual work with variable requirements. Ability to concentrate and maintain accuracy despite frequent interruptions. Critical thinking and organization skills, problem solving, and reasoning capabilities.
LANGUAGE SKILLS: Ability to speak English fluently. Spanish speaking or another language is a plus.
LICENSES, CERTIFICATES, REGISTRATIONS: None
PHYSICAL DEMANDS: The physical demands described herein are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations will 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, talk, and hear, use hands to finger, handle or feel. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee is frequently required to lift and/or move up to 40 pounds.
The special vision requirements for this job are close vision (clear vision at 20 inches or less), color vision (ability to identify and distinguish colors).
WORK ENVIRONMENT: The work environment characteristics described herein are representative of those an employee encounters while performing the essential functions for this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
MedNorth Health Center provides comprehensive health care services, inside a multi-cultural medical/dental clinic, to all individuals; insured, uninsured, and underinsured. The building is heated in winter and air conditioned in the summer with noise levels of moderate to loud. We serve patients who speak multiple languages and who may need the assistance of an interpreter. In this position one may be subject to exposure to copier toner, correction fluid, bright fluorescent lighting, and continuous personal computer exposure.
This job is a Bloodborne Pathogens risk category III position.
GENERAL EXPECTATIONS:
The incumbent is expected to attend work on a daily basis and to be at work on time.
The incumbent is expected to be a team player.
The incumbent is expected to report absences in accordance with personnel policies and procedures.
The incumbent's work is expected to be accurate, neat, and thorough, and completed on time.
The incumbent is expected to have a positive attitude, be cooperative, and considerate of others.
The incumbent is expected to be dependable and is expected to accept responsibility for assignments and duties given.
The incumbent is expected to dress and act in a professional manner and adhere to all safety standards.
The incumbent is expected to participate in staff meetings, be courteous and polite with patients and other staff.
The incumbent is expected to maintain confidentiality.
NOTE: This job description may be changed only with the approval of the Chief Executive Officer, however it should be reviewed at least annually between the employee and the supervisor of the position.
