Position SummaryThe Hospital Compliance Manager is responsible for the day-to-day operational management of the Compliance Office and serves as a generalist supporting all facets of the hospital's compliance program. Under the direction of the Compliance Officer, the Compliance Manager coordinates compliance activities, assists with investigations, manages regulatory reporting and documentation, oversees compliance education logistics, administers compliance software systems, and supports auditing and monitoring initiatives.
The position also serves as the operational lead for the hospital's 340B Drug Pricing Program, coordinating daily program activities, maintaining documentation, supporting compliance audits, and collaborating with pharmacy leadership to ensure ongoing compliance with applicable federal requirements and Health Resources and Services Administration (HRSA) guidance.
The Compliance Manager serves as a resource for hospital departments, physicians, researchers, and leadership regarding compliance processes and assists in maintaining an effective compliance program consistent with the Office of Inspector General (OIG), Centers for Medicare & Medicaid Services (CMS), HRSA, HIPAA, state regulatory requirements, and organizational policies.
Essential Duties and Responsibilities- Manage day-to-day operations of the Compliance Office, including calendars, records, policy maintenance, and Compliance Committee support (agendas, minutes, and reporting).
- Support the Compliance Officer with the annual compliance work plan, including risk assessments, auditing and monitoring, corrective action tracking, and regulatory and Board reporting.
- Serve as operational lead for the 340B Program, including HRSA documentation and annual recertification, audit support, contract pharmacy documentation, and diversion/duplicate discount monitoring, in coordination with Pharmacy, Finance, Revenue Cycle, and Purchasing.
- Coordinate compliance auditing and monitoring activities from scheduling and data collection through corrective action tracking and follow-up review.
- Oversee compliance education logistics, including annual mandatory training, new hire and medical staff education, and learning management system administration.
- Manage the compliance hotline process and support investigations, including HIPAA and privacy incident documentation in partnership with the Privacy Officer.
- Administer the compliance management software platform, including user access, workflow, policy and incident tracking, and dashboard reporting.
- Prepare materials for compliance-related Board and committee meetings, including the Board Audit and Compliance Committee, 340B Oversight, Privacy, Research Compliance, and AI Governance Committees.
- Support research compliance activities (training tracking, conflict-of-interest processes, investigator records) and manage compliance-related vendor agreements, including Business Associate Agreements and audit, hotline, and software vendor contracts.
QualificationsEducationRequired:
- Bachelor's degree in healthcare administration, business administration, compliance, or a related field.
- CHC, CHPC, CHRC, CIA, CFE, PMP, or equivalent experience.
Preferred: 340B ACE certification.
ExperienceRequired:
- Five or more years of healthcare compliance experience, including acute care hospital operations, regulatory compliance support, and audit coordination.
Preferred:
- Experience with 340B Program administration, an academic medical center, research compliance, HIPAA privacy, compliance software platforms, or supporting Board committees.
CertificationsPreferred:
- Certified in Healthcare Compliance (CHC)
- Certified in Healthcare Privacy Compliance (CHPC)
- Apexus 340B University certification
- Certified 340B Professional (if available)
- Project Management certification
KnowledgeKnowledge of:
- OIG Compliance Program Guidance, Medicare and Medicaid regulations, and CMS Conditions of Participation.
- HIPAA Privacy and Security Rules, Stark Law, Anti-Kickback Statute, and False Claims Act.
- HRSA 340B Program requirements and applicable research regulations.
- Applicable OIG, DOJ, and OCR regulations.
Skills- Strong organizational and project management skills, with the ability to manage multiple priorities and maintain attention to detail.
- Analytical thinking, data analysis, and report writing.
- Excellent verbal and written communication and meeting facilitation.
- Regulatory research and policy management.
- Proficiency with Microsoft Office Suite (advanced Excel, Word, PowerPoint) and compliance management software.
- Sound professional judgment, discretion, and emotional intelligence.
Core Competencies- Integrity, ethical decision-making, and confidentiality.
- Collaboration, customer service, and accountability.
- Problem solving, initiative, and adaptability.
- Leadership, professionalism, regulatory awareness, and continuous improvement.
Physical Requirements- Ability to sit for extended periods and work at a computer for extended periods.
- Ability to travel throughout hospital facilities and attend meetings throughout the organization.
Performance ExpectationsSuccess in this role may be measured by:
- Timely completion of annual compliance work plan activities, audits, and monitoring projects.
- Timely investigation documentation and follow-up, and accurate maintenance of compliance records and dashboards.
- Annual HRSA 340B recertification completed accurately and on time, and successful completion of internal and external compliance audits.
- Completion of required compliance committee materials before scheduled meetings, and timely policy review and document management.
- Compliance education completion rates meeting organizational targets (e.g., 69;98%).
- Effective coordination of corrective action plans with documented follow-up.
