Compliance Program Manager

Neighborhood Healthcare•Escondido, CA

16h•Onsite

About The Position

Neighborhood Healthcare (NH) is a private, non-profit 501(C)(3) community health organization dedicated to improving the health and happiness of the communities it serves. Since 1969, NH has provided quality care to over 500,000 medical, dental, and behavioral health visits annually for more than 96,000 people, regardless of their situation or circumstance. The organization values compassion, integrity, professionalism, collaboration, and going above and beyond. The Compliance Program Manager will support NH’s Corporate Compliance Program by leading policy management, delivering compliance education and training, and conducting risk-based compliance audits. This role ensures NH maintains ongoing compliance with HRSA Health Center Program Requirements, federal and state laws, and internal policies. The role reports to the Corporate Compliance Officer and serves as Co-Chair of the Compliance Staff Subcommittee and the Risk Management Subcommittee.

Requirements

Bachelor’s degree in healthcare administration, Public Health, Compliance, Nursing, or related field required.
Minimum of 4 years of experience in healthcare compliance, nursing, administration, or quality required; preferably in an FQHC setting.
Demonstrates high integrity and ethical conduct
Detail-oriented with strong follow-through
Collaborative, supportive, and mission-driven
Thrives in fast-paced, evolving regulatory environments
Strong verbal and written communication skills, including composition and proofreading
Able to interpret and apply written, oral, and visual instructions
Effectively manages multiple priorities and deadlines
Strong planning and organizational skills
Works both independently and collaboratively
Handles confidential information with professionalism and discretion
Follows all safety procedures as outlined in Neighborhood Healthcare’s Illness and Injury Prevention Plan (IIPP) and report any injuries and/or unsafe conditions immediately
Maintains current knowledge of policies and procedures as they relate to safe work practices
Follows all safety procedures and reports unsafe conditions
Uses appropriate body mechanics to ensure an injury free environment
Familiarity with location of nearest fire extinguisher and emergency exits
Follows all infection control procedures including blood-borne pathogen protocols
Maintains privacy of all patients, employees and volunteer information and access such information only on a need-to-know basis for business purposes
Comply with all regulations regarding corporate integrity and security obligations
Reports all behavior and/or activity that are unethical, fraudulent, or unlawful

Nice To Haves

Familiarity with HRSA Health Center Program Requirements and Site Visit Protocol is strongly preferred.
Clinical experience strongly preferred

Responsibilities

Maintain the organization’s library of policies and procedures and ensure policies remain aligned with HRSA requirements, including HRSA’s specific expectations for Board‑approved and operational policies.
Oversee scheduled policy reviews (at least every three years or more frequently if required by federal/state regulations) in conjunction with Compliance & Risk Coordinator.
Draft, revise, and standardize policies in collaboration with subject matter experts as needed.
Ensure policies reflect updated federal regulations and HRSA’s Compliance Manual, including terminology and regulatory citation changes (e.g., updates to Uniform Guidance per the 2025 Compliance Manual revision).
Maintain proper version control and documentation standards.
Develop, monitor, and track compliance training programs for all staff as needed, consistent with ongoing compliance expectations in HRSA’s Compliance Manual.
Monitor onboarding compliance training for new employees and role‑specific training for leadership, clinical providers, billing teams, and administrative staff.
Ensure staff understand key compliance risks including HIPAA privacy/security, billing/coding integrity, Scope of Project limits, Sliding Fee Discount Program requirements, FTCA, and 340B.
Develop educational materials (e.g., toolkits, presentations, staff messages, job aids).
Track training completion and report gaps to the Corporate Compliance Officer.
Oversee existing, and conduct as needed, routine and risk‑based internal audits across operational, clinical, and/or financial domains, aligning with HRSA’s expectation that health centers perform internal monitoring and demonstrate ongoing compliance.
Audit areas include: Sliding Fee Discount Program, Billing and coding compliance, HIPAA Privacy/Security, Credentialing and privileging documentation, FTCA risk management elements, 340B procedures (if delegated by pharmacy/340B team), UDS data integrity and reporting workflows.
Prepare written audit reports summarizing methodology, findings, and recommendations based on departmental compliance audit reports.
Track and validate departmental corrective action plans (CAPs), ensuring timely follow‑through.
Maintain readiness for the HRSA Operational Site Visit (OSV) by ensuring required documents, sample lists, and policies meet the structure and content expectations outlined in the Site Visit Protocol.
Assist with collecting, organizing, and naming evidence according to HRSA’s Required Documents & File Naming Convention guidance.
Support mock OSV assessments and coordinate with internal stakeholders to resolve identified gaps.
Support the Compliance Officer in day‑to‑day operations of the Corporate Compliance Program.
Research and respond to compliance related questions from the organization’s staff.
Track trends of internal compliance concerns; assist Risk Manager with clinically related investigations.
Maintain compliance logs as needed (e.g., audit logs, policy review logs, CAP tracking tools).
Prepare quarterly compliance dashboards and reports for the Compliance Staff Subcommittee, Risk Management Subcommittee, Corporate Compliance Committee and Board of Directors.
Assist with updating the annual Compliance Work Plan.