Compliance Manager

The Compliance Manager runs the day-to-day compliance program for a multi-state, peer-workforce organization serving individuals as part of value-based arrangements. The organization employs and is led by people with lived experience, delivers certified peer support services across several states, and is subject to federal health care fraud and abuse law, state Medicaid and peer certification requirements, and the compliance program expectations set out in the OIG’s General Compliance Program Guidance.

This is a hands-on execution role. Program direction, oversight, and board reporting are provided by the fractional Compliance Officer; legal judgment is supplied by the fractional General Counsel; employment administration sits with the organization. The Compliance Manager owns the operating work of the program - monitoring and auditing on a defined schedule, keeping policies current across all regulatory environments, ensuring training and screenings are accomplished on time, investigating reported concerns, managing and/or overseeing PC entity compliance, managing and /or overseeing collaborative physician agreements, auditing care pathways from a compliance perspective, and driving corrective actions to documented closure.

The organization is looking for someone who can do this work in a collaborative setting: rigorous about regulatory requirements, and equally capable of building compliance practices that strengthen rather than undermine a culture built on lived experience. This position reports to the Sr. Director, People Operations with a matrixed reporting relationship to the fractional Compliance Officer who is engaged by the organization as an independent contractor.

• In coordination with the interdisciplinary team, maintain the compliance policy library with annual review, version control, documented approval, and publication to the workforce. Ensure policies are crafted in plain language accessible to the workforce, and confirm they are understood rather than merely distributed.
• In coordination with the interdisciplinary team, maintain state-specific addenda or crosswalks covering peer certification, scope of practice, supervision, and Medicaid billing requirements in each state.
• In coordination with the interdisciplinary team, maintain the Code of Conduct and obtain annual attestation from all workforce members, contractors, and applicable vendors.

• Serve as the operational point of contact for compliance across all fh locations.
• Prepare the compliance dashboard, agendas, and minutes for the Compliance Committee and for Board or Committee reporting.
• Maintain the annual compliance work plan and report progress against it.
• Maintain the compliance risk assessment, refreshed at least annually and after any material change in service line, payer mix, state footprint, or contract structure.

• Deliver and document compliance and fraud, waste, and abuse training at hire and annually, tracking completion to 100% with escalation for non-completion.
• Build role-specific training for certified peers and their supervisors on documentation standards, scope of practice, boundaries and dual relationships, confidentiality, and the requirements of 42 C.F.R. Part 2 where substance use disorder records are involved.
• Provide targeted education in response to audit findings, investigations, and regulatory change.

• Administer the compliance hotline and other reporting routes; triage intake, maintain the case log, and track every matter to disposition.
• Maintain and actively communicate company policies. 
• Ensure reporting routes work for a distributed, largely field-based workforce operating outside traditional office settings.

• In conjunction with the People Team, conduct exclusion and sanction screening — the OIG List of Excluded Individuals and Entities, the System for Award Management, and each applicable state Medicaid exclusion list — at hire and monthly thereafter for employees, contractors, and vendors, retaining evidence of each check.
• Oversee, and in conjunction with the People Team, ensure peer certification, license, and background check verification in each state, including expiration tracking and renewal follow-up.
• Partner with the People Team to apply disciplinary standards consistently across states and levels of seniority, and document that consistency.

• Execute the annual audit and monitoring plan, including documentation audits of peer support services against the applicable state Medicaid service definition, supervision requirement, and authorization criteria.
• Monitor encounter data for accuracy, completeness, and timeliness, with attention to services rendered but not documented and services documented but not supported.
• Monitor supervision documentation - whether required supervisory contact occurred, was documented, and met state frequency and supervisor qualification standards.
• Conduct oversight of delegated and subcontracted functions; support payer audits, delegation audits, and state program integrity reviews.
• Produce written audit reports identifying findings, root cause, and corrective action, classifying each finding by whether it reflects a legal requirement, a contractual requirement, or internal policy.

• Conduct and document compliance investigations, coordinating with the Sr. Director, People Ops,  fractional Compliance Officer, the General Counsel, clinical leadership, and outside counsel as circumstances require.
• Maintain the corrective action log and verify remediation through follow-up testing rather than assurance alone.
• Support identification, quantification, and reporting of overpayments within applicable deadlines, and support any self-disclosure decision made by the fractional Compliance Officer, the General Counsel, and leadership.
• Prepare required notifications to payers and state agencies; support breach assessment and notification.

• Bachelor’s degree, or an equivalent combination of education and directly relevant experience.
• Health care compliance experience with direct, hands-on exposure to Medicaid, Medicaid managed care, or Medicare Advantage requirements. 
• Working knowledge of the federal fraud and abuse framework — Anti-Kickback Statute, False Claims Act, Civil Monetary Penalties Law, and the physician self-referral law — sufficient to recognize an issue and escalate it accurately.
• Working knowledge of HIPAA privacy and security requirements.
• Experience operating across multiple state regulatory environments, or demonstrated ability to research and apply unfamiliar state requirements accurately.
• Demonstrated ability to operate as the sole compliance staff member, setting and holding a schedule without daily direction.
• Capacity to work independently with limited on-site supervision, and to maintain objectivity when findings are unwelcome to leadership.

• Experience in behavioral health, substance use disorder services, recovery support, or peer-delivered services.
• Working knowledge of 42 C.F.R. Part 2.
• Experience in a lived-experience organization, or demonstrated understanding of the peer model.
• Experience supporting payer delegation audits or state program integrity reviews.
• Experience in an organization operating under capitated or value-based arrangements.

Remote or hybrid work with periodic travel to state operations, payer meetings, and audits. Occasional work outside standard hours in response to time-sensitive investigations, breach assessments, or regulatory deadlines. The role involves regular exposure to sensitive information, including substance use disorder treatment records and personnel matters.