Policy & Procedure Analyst

One Community Health•Sacramento, CA

About The Position

The Policy & Procedure Analyst plays a critical role in ensuring regulatory compliance, operational consistency, and quality improvement across all organizational functions. The analyst also supports compliance investigations, incident review processes, and corrective action planning to strengthen organizational safeguards and ensure regulatory adherence. Essential Functions Develop, write and revise organizational policies and procedures in accordance with federal, state, and local regulations, including HRSA requirements, HIPAA, 42 CFR Part 51c, Medicare/Medicaid, and other applicable healthcare regulations. Collaborate with department leaders, compliance staff, and clinical directors to identify policy needs and ensure alignment with operational practices. Ensure policies reflect current best practices in FQHC operations, including special programs such as 340B Drug Pricing Program, Vaccines for Children (VFC), Street Medicine, and telehealth services. Maintain a centralized policy repository with version control and ensure accessibility to all staff. Coordinate the Forms Committee and manage standardized forms development and approval processes. Monitor changes in federal and state healthcare regulations and update policies accordingly. Ensure policies support compliance with Joint Commission standards, FTCA coverage requirements, and HRSA Health Center Program requirements. Coordinate policy review cycles to ensure all policies are reviewed and updated within established timeframes. Support preparation for regulatory audits, site visits, and accreditation surveys by maintaining current, comprehensive policy documentation. Develop policies supporting risk management, patient safety, and quality improvement initiatives. Lead and coordinate the organizational incident investigation process, including intake, classification, and tracking of reported incidents, adverse events, near-misses, and grievances. Conduct or support structured root cause analyses (RCA) and failure mode and effects analyses (FMEA) to identify systemic factors contributing to incidents. Develop, implement, and monitor corrective action plans (CAPs) resulting from investigations, ensuring timely completion and effectiveness verification. Collaborate with clinical, operations, and compliance teams to investigate and document incidents involving patient safety, privacy breaches, workplace injuries, or regulatory non-compliance. Review and revise relevant policies and procedures in response to investigation findings to prevent recurrence and strengthen organizational safeguards. Ensure incident investigation processes comply with applicable regulations, including HIPAA breach notification requirements, FTCA reporting obligations, and HRSA Health Center Program expectations. Prepare and present investigation summary reports and trend analyses to Compliance Department Leadership, Quality Improvement Committee, and leadership as appropriate. Maintain a confidential and legally protected incident investigation file system, ensuring records are retained in accordance with applicable state and federal requirements. Develop and deliver policy training programs for staff at all levels. Create user-friendly policy summaries, quick reference guides, and implementation tools. Partner with department leaders to ensure effective rollout of new or revised policies. Track policy acknowledgment and ensure mandatory training completion Provide ongoing support to staff regarding policy interpretation and application. And other duties as assigned

Requirements

Bachelor's degree in Healthcare Administration, Public Health, Business Administration, or related field; equivalent professional experience may be considered in lieu of degree.
Expertise in the following areas, typically gained from 2+ years in a similar capacity: policy development, healthcare compliance, or healthcare administration.
Experience writing healthcare policies and procedures in a clinical or regulatory environment.
Knowledge of federal healthcare regulations including HIPAA, HRSA requirements, and Medicare/Medicaid compliance.
Experience with incident investigation, root cause analysis, or patient safety programs.
Excellent writing, editing, and communication skills.

Nice To Haves

Certified in Healthcare Compliance (CHC), Certified in Healthcare Privacy Compliance (CHPC), Certified Professional in Healthcare Quality (CPHQ), or Certified Professional in Healthcare Risk Management (CPHRM).
Demonstrated experience working in a Federally Qualified Health Center (FQHC) or community health center setting.
Experience with policy management platforms such as Navex, PolicyStat, or similar document control systems.
Familiarity with FQHC special programs including 340B Drug Pricing, Vaccines for Children (VFC), Ryan White, or Street Medicine.
Ability to collaborate effectively across a broad spectrum of backgrounds and perspectives. Candidates who demonstrate inclusive thinking and interpersonal awareness help strengthen our commitment to equitable and compassionate care for all.

Responsibilities

Develop, write and revise organizational policies and procedures in accordance with federal, state, and local regulations, including HRSA requirements, HIPAA, 42 CFR Part 51c, Medicare/Medicaid, and other applicable healthcare regulations.
Collaborate with department leaders, compliance staff, and clinical directors to identify policy needs and ensure alignment with operational practices.
Ensure policies reflect current best practices in FQHC operations, including special programs such as 340B Drug Pricing Program, Vaccines for Children (VFC), Street Medicine, and telehealth services.
Maintain a centralized policy repository with version control and ensure accessibility to all staff.
Coordinate the Forms Committee and manage standardized forms development and approval processes.
Monitor changes in federal and state healthcare regulations and update policies accordingly.
Ensure policies support compliance with Joint Commission standards, FTCA coverage requirements, and HRSA Health Center Program requirements.
Coordinate policy review cycles to ensure all policies are reviewed and updated within established timeframes.
Support preparation for regulatory audits, site visits, and accreditation surveys by maintaining current, comprehensive policy documentation.
Develop policies supporting risk management, patient safety, and quality improvement initiatives.
Lead and coordinate the organizational incident investigation process, including intake, classification, and tracking of reported incidents, adverse events, near-misses, and grievances.
Conduct or support structured root cause analyses (RCA) and failure mode and effects analyses (FMEA) to identify systemic factors contributing to incidents.
Develop, implement, and monitor corrective action plans (CAPs) resulting from investigations, ensuring timely completion and effectiveness verification.
Collaborate with clinical, operations, and compliance teams to investigate and document incidents involving patient safety, privacy breaches, workplace injuries, or regulatory non-compliance.
Review and revise relevant policies and procedures in response to investigation findings to prevent recurrence and strengthen organizational safeguards.
Ensure incident investigation processes comply with applicable regulations, including HIPAA breach notification requirements, FTCA reporting obligations, and HRSA Health Center Program expectations.
Prepare and present investigation summary reports and trend analyses to Compliance Department Leadership, Quality Improvement Committee, and leadership as appropriate.
Maintain a confidential and legally protected incident investigation file system, ensuring records are retained in accordance with applicable state and federal requirements.
Develop and deliver policy training programs for staff at all levels.
Create user-friendly policy summaries, quick reference guides, and implementation tools.
Partner with department leaders to ensure effective rollout of new or revised policies.
Track policy acknowledgment and ensure mandatory training completion
Provide ongoing support to staff regarding policy interpretation and application.
And other duties as assigned