Agency Compliance Coordinator

JOB SUMMARY

The Agency Compliance Coordinator is a mid-management position responsible for coordinating and monitoring
compliance across all Hope Haven programs and departments. This role ensures the agency meets the requirements of
CARF accreditation, NC DHHS licensure under 10A NCAC 27G, NC Medicaid clinical coverage policies, LME/MCO
contracts, and federal privacy laws for every service the agency provides, including its residential treatment services and the
outpatient services it will add as it grows. The coordinator serves as the agencys central resource on compliance,
communicating with staff at every level and in every department, and reports all compliance activities, findings, and
concerns to the Director of Admission and Regulatory Compliance to keep Hope Haven survey -ready year-round.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Agency Compliance Program

Coordinate the agencys compliance program and annual compliance work plan under the direction of the Director
of Admission and Regulatory Compliance, including an annual risk assessment of all programs and departments.
Coordinate the Compliance and Quality Committee, including agendas, minutes, and tracking of action items.
Provide monthly compliance reports to the Director and prepare quarterly summaries for the Director to share with
senior leadership and the Board.
Maintain a confidential process for staff to report compliance concerns and report all concerns promptly to the
Director.

Service Compliance

Monitor compliance with the clinical coverage policy, licensure rules, and documentation standards for each
residential and outpatient service the agency offers.
Verify service requirements are met, such as service orders, assessments and their timeframes, Person -Centered
Plans, minimum service hours, staffing ratios, and required documentation.
Support readiness for new services by coordinating licensure applications, LME/MCO contracting and credentialing
requirements, policy development, and required staff training before launch, and report readiness status to the
Director.

Accreditation and Licensure

Maintain CARF accreditation by monitoring conformance to standards, coordinating the Annual Conformance to
Quality Report, and preparing for resurvey.
Coordinate preparation for DHHS licensure surveys, complaint investigations, and LME/MCO monitoring reviews,
and draft plans of correction with department leaders for the Directors review by required deadlines.
Monitor incident reporting through the state incident reporting system, ensuring incidents are reported, reviewed,
and addressed within required timeframes.
Track changes in state and federal regulations, CARF standards, and Medicaid bulletins, and report their impact to
the Director.

Medicaid, Privacy, and Records Compliance

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 any potential overpayments to the Director so they can be
repaid within federally required 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, release of information, and the
notice prohibiting redisclosure.
Oversee records management, records requests, and retention for active and discharged client files.
Report potential privacy breaches to the Director immediately and assist with investigations and required
notifications.
Adhere to the Residents Rights Policy, the agency Code of Ethics, and professional and ethical boundaries.
Perform other duties as assigned by the Director.

Communication, Training, and Collaboration

Serve as the agencys primary internal point of contact for compliance with questions, and communicate regularly
with staff in all departments, including clinical, admissions, residential, medical, family programs, workforce
development, business, finance, HR, operations, and food services.
Share regular compliance updates with staff, such as a monthly compliance brief approved by the Director, and
attend department meetings as needed.
Coordinate annual compliance, privacy, and ethics training, and track staff completion of training required by each
clinical coverage policy.
Track staff licenses, certifications, and credentials, and notify supervisors and the Director before expirations.
Maintain the agencys Policy and Procedure Manual, coordinate annual reviews, and ensure staff have access to
current policies.
Supervise compliance or records staff as assigned by the Director.

Physical Demands

May sit, stand, and walk for extended periods throughout the workday.
Frequently uses a computer and standard office equipment.
Occasionally lifts or moves materials weighing up to 20 pounds.

Work Environment

Work is performed in a professional work environment with regular interaction with employees, clients, and other
stakeholders.

Pre-Employment Requirements

All offers of employment are contingent upon successful completion of Hope Havens pre -employment screening
requirements, which may include background verification and other screening requirements applicable to the position and
consistent with applicable law.
This position may require operating a Hope Haven vehicle or transporting activity materials on an occasional or as-needed
basis. When assigned driving duties, the employee must maintain a valid drivers license and be insurable under Hope
Havens automobile insurance policy.

Disclaimer

This job description describes the general nature and level of work performed by employees assigned to this position. It is
not intended to be an exhaustive list of all duties, responsibilities, or qualifications. Duties and responsibilities may
change based on organizational needs.

Qualifications

Minimum Qualification Requirements

Bachelors degree in human services, Health Care Administration, Business Administration, or a related field
required.
Minimum of three (3) 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; experience with KIPU preferred.
Qualified Professional (QP) status or Certification in Healthcare Compliance (CHC) preferred.
Strong communication and relationship-building skills, with the ability to explain requirements clearly to staff at all
levels.
Strong organizational and project management skills, with the ability to manage multiple deadlines.
Knowledge of the dynamics of the disease of addiction and its treatment.
Must have a valid drivers license and be insured by Hope Havens carrier.