Compliance Officer

Greater Lawrence Family Health Center•Methuen, MA

About The Position

Established in 1980, the Greater Lawrence Family Health Center (GLFHC) is a multi-site mission-driven non-profit organization employing over 700 staff whose primary focus is providing the highest quality patient care to residents throughout the Merrimack Valley. Nationally recognized as a leader in community medicine (family practice, pediatrics, internal medicine, and geriatrics), GLFHC has clinical sites throughout the service area and is the sponsoring organization for the Lawrence Family Medicine Residency program. GLFHC is currently seeking a Compliance Officer to join our team. The Compliance Officer is responsible for overseeing the development, implementation, and daily operations of the Health Center’s Corporate Compliance Program. This position promotes compliance with applicable federal, state, and local regulations; ensures adherence to internal policies and Standards of Conduct; manages the incident reporting process; and serves as the organization’s HIPAA Privacy Official. The Compliance Officer works collaboratively across departments to monitor compliance risks, support staff education, and maintain regulatory readiness.

Requirements

7+ years of experience in healthcare compliance or regulatory roles; FQHC experience strongly preferred.
Experience in policy management, HIPAA privacy, and incident/complaint investigation.
Strong communication, facilitation, and interpersonal skills.
Excellent attention to detail, organization, and ability to manage competing deadlines.
Proficiency with Microsoft Office and web-based compliance tools.
Bachelor’s degree required; equivalent experience considered.

Nice To Haves

Compliance certification (CHC, CHPC, or similar) preferred.

Responsibilities

Oversees implementation and maintenance of the Corporate Compliance Program and annual Compliance Work Plan.
Ensures organizational adherence to compliance policies, procedures, and Standards of Conduct.
Promotes awareness of compliance obligations through communication and education initiatives, including education on the Compliance Hotline.
Serves as primary liaison for Compliance for staff and leadership.
Provides regular reports to the CEO and quarterly reports to the Board/Board Committee.
Coordinates development, annual review, revision, approval, and retirement of policies and procedures.
Ensures policies are regulatory compliant, consistent, and properly formatted.
Maintains a centralized, accessible Policy & Procedure repository and MOU/MOA/contract repository.
Tracks policy lifecycle timelines and maintains historical and archived versions.
Administers the electronic incident reporting system, ensuring it is functional and accessible.
Provides user training and support.
Assigns incidents to appropriate managers and ensures timely follow-up.
Monitors incident trends, prepares reports, and supports corrective action planning.
Investigates privacy complaints, potential breaches, and unauthorized disclosures.
Ensures documentation of investigations and compliance with breach notification requirements.
Oversees Business Associate Agreement (BAA) process in collaboration with contracting staff.
Coordinates regulatory audit readiness (e.g., HRSA OSV, DPH, CMS, OCR).
Prepares required documentation and ensures departments are aware of compliance responsibilities.
Assists in maintaining HRSA-required documents (e.g., Form 5A/B/C updates).
Serves as a resource to departments during audits and regulatory reviews.
Maintains ongoing official communication with the Board of Registration in Medicine – specifically through mandatory reporting of PCA Annual and Semi-Annual reports for the GLFHC Board of Directors.
Responsible for FTCA and annual FTCA deeming process as well as any FTCA claims from DOJ and requests from Office of General Counsel.
Works alongside SVP, CMIO to ensure regulatory compliance with state and federal cybersecurity standards.
Review binder of cybersecurity coverage at renewal with SVP, CMIO and CFO to ensure appropriate coverage.
Assists CMIO as needed in navigating NIST cybersecurity framework and core functions.
Ensures that the Security Risk Assessment is completed on a yearly basis by 12/31 and assist SVP, CMIO with any related items and tracking progress to mitigate associated risks.
Tracks organizational licenses and certificates, notifying departments of upcoming expirations.
Maintains current and archived regulatory documents for reference and audits.
Ensures accreditation-related documents are available to leadership.
Partners with Human Resources to support compliance and privacy training for new hires.
Ensures ongoing staff compliance education, including annual refreshers.
Supports department managers in delivering area-specific compliance training.
Conducts or coordinates investigations of compliance concerns.
Documents findings and supports implementation of corrective action plans.
Identifies potential areas of risk and collaborates with leadership to develop mitigation strategies.
Works closely with Quality, HR, IT, Finance, Operations, Pharmacy and other departments on compliance matters.
Collaborates with key stakeholders to ensure adherence to 340B program requirements, including eligibility, diversion prevention, and audit readiness, while implementing corrective actions and safeguarding compliance with HRSA and organizational standards.
Ensures compliance considerations are integrated into organizational initiatives.
Maintains strict confidentiality regarding all compliance matters.
Serves as a member of the Quality Council to integrate and ensure compliance in system-wide initiatives.
Serves as a member of the Safety and Sentinal Event Committee.
Serves as GLFHC’s Risk Manager and Claims Point of Contact for HRSA: Coordinates Risk Management Functions daily, to maximally ensure that identification of risk exposure, assessment, appraisal and loss prevention are carried out, so that the Health Center remains safe for its patients, families, and employees.
Identifies and limits legal exposures and directly assists outside counsel/Department of Justice AUSAs assigned to federal tort cases in the handling / defense of legal claims.
Responsible for the management and processing of all claims-related activities on a daily basis.
Responsible for ensuring the preservation of all GLFHC documentation related to any actual or potential claim or complaint (including issuing, re-issuing and all education related to Litigation Holds).
Responsible for ensuring that all FTCA-related notification of intent to sue or other service of process/summons that GLFHC or its providers, receives related to any alleged claim or complaint, is promptly sent to the HHS Office of General Counsel General Law Division.
Responsible for working in full cooperation with the HHS Office of General Counsel Law Division or, if deemed covered, the Department of Justice attorneys that are assigned to defend.