Agency Compliance Coordinator

HOPE HAVEN INC•Charlotte, NC

4d•$55,000 - $60,000•Onsite

About The Position

The Agency Compliance Coordinator is a mid-management position responsible for coordinating and monitoring compliance across Hope Haven programs and departments. The role ensures compliance with CARF accreditation, North Carolina DHHS licensure under 10A NCAC 27G, NC Medicaid clinical coverage policies, LME/MCO contracts, and federal privacy laws across existing residential treatment services and outpatient services added as the agency grows. The coordinator is the agency’s central internal compliance resource, communicates with staff at all levels, and reports compliance activities, findings, and concerns to the Director of Admission and Regulatory Compliance to keep the agency survey-ready year-round. The coordinator manages the agency compliance program and work plan, monitors service and documentation requirements, supports new-service readiness, coordinates accreditation and licensure reviews, conducts audits, and tracks corrective actions. The role also supports HIPAA and 42 CFR Part 2 compliance, records management, staff training and credential tracking, policy maintenance, and communication of compliance updates. The coordinator may supervise compliance or records staff as assigned by the Director.

Requirements

Bachelor’s degree in human services, health care administration, business administration, or a related field.
At least three 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 27G licensure rules.
Knowledge of HIPAA and 42 CFR Part 2 confidentiality requirements.
Experience with electronic health records.
Strong communication and relationship-building skills, including the ability to explain requirements clearly to staff at all levels.
Strong organizational and project management skills and the ability to manage multiple deadlines.
Knowledge of the dynamics of addiction and its treatment.
Valid driver’s license and insurability under Hope Haven’s automobile insurance policy.

Nice To Haves

Experience with KIPU.
Qualified Professional (QP) status or Certification in Healthcare Compliance (CHC).

Responsibilities

Coordinate the agency compliance program and annual compliance work plan, including an annual risk assessment of all programs and departments.
Coordinate the Compliance and Quality Committee, including agendas, minutes, and action-item tracking.
Provide monthly compliance reports to the Director and prepare quarterly summaries for senior leadership and the Board.
Maintain a confidential process for staff to report compliance concerns and promptly report concerns to the Director.
Monitor compliance with clinical coverage policies, licensure rules, and documentation standards for residential and outpatient services.
Verify service requirements, including service orders, assessments and timeframes, Person-Centered Plans, minimum service hours, staffing ratios, and required documentation.
Coordinate licensure applications, LME/MCO contracting and credentialing, policy development, and required staff training for new services, and report readiness status to the Director.
Monitor CARF standards, coordinate the Annual Conformance to Quality Report, and prepare for resurvey.
Coordinate preparation for DHHS licensure surveys, complaint investigations, and LME/MCO monitoring reviews; draft plans of correction with department leaders for the Director’s review by required deadlines.
Monitor incident reporting through the state incident reporting system and ensure incidents are reported, reviewed, and addressed on time.
Track changes in state and federal regulations, CARF standards, and Medicaid bulletins, and report their impact to the Director.
Conduct monthly documentation audits and pre-billing and post-payment audits of Medicaid and state-funded services using agency audit tools, and report findings to the Director.
Track corrective action plans to completion and report potential overpayments to the Director so they can be repaid within required federal 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, releases of information, and notices prohibiting redisclosure.
Oversee records management, records requests, and retention for active and discharged client files.
Immediately report potential privacy breaches to the Director and assist with investigations and required notifications.
Adhere to the Resident’s Rights Policy, agency Code of Ethics, and professional and ethical boundaries.
Serve as the agency’s primary internal point of contact for compliance questions and communicate regularly with staff across departments.
Share regular compliance updates with staff, including a monthly compliance brief approved by the Director, and attend department meetings as needed.
Coordinate annual compliance, privacy, and ethics training and track completion of training required by clinical coverage policies.
Track staff licenses, certifications, and credentials, and notify supervisors and the Director before expirations.
Maintain the Policy and Procedure Manual, coordinate annual reviews, and ensure staff can access current policies.
Supervise compliance or records staff as assigned by the Director.
Perform other duties as assigned by the Director.