Compliance/Risk Management Officer

MEDNORTH HEALTH CENTER•Wilmington, NC

8d•Onsite

About The Position

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 Ensure compliance with clinical quality standards, patient safety protocols, and behavioral health privacy requirements. Dental Services Monitor compliance with infection control, sterilization protocols, and dental-specific regulatory standards. Pharmacy Services 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 safety. 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. 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.

Requirements

Bachelor’s degree in Healthcare Administration, Nursing, Public Health, or related field required
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
Excellent interpersonal and customer service skills.
Teamwork and communication skills are essential.
Treat all patients, co-workers, and managers with courtesy and respect.
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.
Ability to speak English fluently.

Nice To Haves

Master’s degree preferred
Certified in Healthcare Compliance (CHC)
Certified Professional in Healthcare Risk Management (CPHRM)
Certified Professional in Healthcare Quality (CPHQ) (optional)
Spanish speaking or another language is a plus.

Responsibilities

Lead and oversee a comprehensive compliance and risk management program across a multi-site Federally Qualified Health Center (FQHC).
Ensure compliance with federal (HRSA/FQHC, FTCA), state (North Carolina), and accreditation (Joint Commission) requirements.
Maintain adherence to HIPAA, OSHA, infection control standards, and pharmacy regulatory requirements.
Lead enterprise-wide risk management, incident investigation, and malpractice prevention efforts.
Ensure regulatory compliance across all clinical services: Medical & Behavioral Health, Dental Services, and Pharmacy Services.
Develop, implement, and maintain an organization-wide compliance program.
Serve as a primary liaison during external audits, accreditation reviews, and regulatory inspections.
Serve as or support the HIPAA Privacy and Security Officer.
Ensure compliance with OSHA standards and oversee workplace safety programs.
Review, investigate, and analyze incident reports, adverse events, and near-miss occurrences.
Develop, review, and update organizational policies and procedures.
Provide ongoing compliance and risk management training to staff and leadership.
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.
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.
Work as part of a team to provide high-quality, patient-focused care within the Patient Centered Medical Home model.
Ensure patients have timely access to services, support coordinated care, and contribute to quality improvement efforts.
Cooperate with the compliance program without fear of retaliation.