Compliance Manager

Our Culture: Why Work with Us?

Joining Outer Cape Health Services isn't just about taking on a new role; it's about embracing a mission that goes beyond the day-to-day. Here, you become part of a dedicated team committed to safeguarding and nurturing invaluable community health resources. Our ethos is built on creating a vibrant and inclusive workplace where every team member is valued and recognized for their unique contributions.

Who We Are:

Our mission is to provide a full range of primary health care and supportive social services that promote the health and well-being of all who live in or visit the ten outermost towns of Cape Cod.

OCHS now cares for more than 20,000 patients annually, and no one is denied access to services due to an inability to pay. Founded in 1987 through the merger of Health Associates of Provincetown (established in 1972) and the AIM Medical Center in Wellfleet (established in 1966), Outer Cape Health has a long history of successful growth and expansion in pursuit of this mission. As a Patient-Centered Medical Home, OCHS holds itself to the highest standards.  Ensuring patients have access to care when they need it and request it and validating that staff are working at the top of their licensures, are the foundations of this model.

Our Core Competencies:

At Outer Cape Health Services, our core competencies are the foundation upon which our organization is built, guiding us in our mission to deliver exceptional health services to our communities. Our focus on fostering teamwork ensures that we operate as a cohesive unit, valuing each member's contribution and working synergistically towards common goals. Integrity and honesty stand at the heart of everything we do, creating a culture of trust and respect among our team and the communities we serve. Embracing technology, we continually seek innovative solutions to enhance our services and operations. Finally, being patient-centered, we prioritize the needs and well-being of those we serve, striving to exceed expectations and make a meaningful difference in their lives.

A Day in the Life of this Role:

Reporting to the Senior Director of Operations, the Compliance Manager is responsible for implementing and maintaining an effective, organization-wide compliance program and emergency management plan that ensures adherence to HRSA requirements, FTCA compliance, federal and state regulations, HIPAA standards, and internal policies. The Compliance Officer is responsible for keeping up-to-date with all regulations and requirements, maintaining OCHS' policy and procedure library, conducting internal audits, maintaining certifications and licenses, managing compliance risk, maintaining the organization's emergency preparedness plans, and coordinating training for the staff and Board of Directors to promote a culture of accountability and ethical behavior.

This role works closely with operational, clinical, finance, and administrative teams and provides regular reports to the CEO and Board's Compliance Committee. The Compliance Manager supports the Senior Director of Operations and Chief Strategy Officer in ensuring that compliance considerations are incorporated into operational processes and strategic initiatives.

Summary of Duties:

Regulatory Compliance

• Maintain an active, effective compliance program consistent with HRSA, FTCA, OIG, CMS, and state requirements.
• Lead efforts for both announced and unannounced site visits from regulatory agencies such as HRSA and DPH. This includes leading the organization's preparation for site visits, managing an actual site visit, and ensuring timely follow-up when compliance issues are identified.
• Ensure OCHS obtains and maintains all necessary licenses for services and programs requiring state and/or federal licensing.
• Conduct routine risk assessments and manage the annual compliance workplan.
• Monitor regulatory updates and communicate relevant changes to leadership and staff.
• Oversee the development, review, and maintenance of compliance-related policies and procedures.

Emergency Preparedness

• Implement and maintain the organization's comprehensive emergency management plan, ensuring alignment with federal, state, and local regulatory requirements.
• In coordination with other key stakeholders such as Facilities, Clinical, Operations and/or local resources (such as the fire and/or police departments), plan, schedule, and facilitate emergency drills, tabletop exercises and after-action reviews. Document outcomes and track corrective action plans.
• Coordinate cross-departmental collaboration to ensure all functional areas understand and fulfill their roles in emergency preparedness and response.
• Provide leadership and coordination during emergency events, supporting decision-making and documentation in accordance with the emergency preparedness plan.

Auditing, Monitoring & Investigations

• Conduct internal audits related to billing, documentation, HIPAA, operational compliance, and programmatic requirements.
• Monitor for potential compliance issues and initiate corrective action plans when needed.
• Lead internal investigations of reported compliance concerns, documenting findings and recommended remediation.
• Track and analyze compliance trends to identify systemic risks.

HIPAA & Privacy Oversight

• Serve as the HIPAA Privacy Officer. Will need to coordinate privacy activities with IT Security and Operations.
• Manage breaches, incident response, staff education, and risk assessments.
• Ensure compliance with HIPAA Privacy and Security Rule requirements.

Training & Education

• Develop and deliver trainings related to compliance and HIPAA. Examples include: annual training for the Board of Directors; training at new hire orientation; and periodic compliance training for all staff and targeted training for high-risk areas.
• Maintain documentation of training and ensure timely completion organization-wide.
• Serve as a resource to leaders and staff regarding ethical conduct, regulatory requirements, and best practices.

Reporting & Governance

• With the CEO, attend the Board's Compliance Committee. Prepare compliance reports and provide updates for the Compliance Committee.
• As needed, attend the Board of Directors meeting to provide updates.
• Maintain documentation of compliance activities and corrective action plans.
• Ensure compliance program transparency and escalation of significant issues.

General Responsibilities

• Travel to all OCHS sites, as required.
• Other related duties and projects as assigned.

What We Need from You:

• Bachelor's degree required; Master's degree or professional certification (CHC, CHPC, CCEP) preferred.
• 3–5+ years of experience in compliance, risk management, quality, auditing, or regulatory affairs in a healthcare setting. Experience in a FQHC or ambulatory care setting strongly preferred.
• Strong knowledge of HRSA, FTCA, HIPAA, Medicare/Medicaid billing requirements, and OIG compliance guidance.
• Excellent communication, analytical, and investigative skills.
• Excellent organizational abilities.
• Proficiency in computer skills including Epic, Outlook, Microsoft Office, OneDrive, etc.
• Ability to exercise sound judgment and solve problems in a timely manner.
• Ability to adhere to strict confidentiality standards.
• Demonstrated ability to work effectively both as a team member and independently.
• Demonstrated ability to work in a culturally diverse and inclusive environment.
• Excellent judgment and ability to solve problems in a timely manner.
• Ability to adhere to strict confidentiality standards.
• Demonstrated ability to work in a culturally diverse and inclusive environment

AAP/EEOC Statement

Outer Cape Health Services is committed to providing equal employment opportunity in all our employment programs and decisions. Discrimination in employment on the basis of any protected class under federal, state, or local law is a violation of our policy and is against the law. Equal employment opportunity is provided to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, covered veterans' status, marital status, personal appearance, sexual orientation, family responsibilities, matriculation, political affiliation, or any other protected characteristic. This policy applies to all terms and conditions of employment, including, but not limited to, recruitment and hiring, placement, promotion, termination, reductions-in-force, recall,