Director of Compliance

Director Of ComplianceMission Statement: The Salvation Army is an international movement, an evangelical part of the universal Christian Church. Its message is based on the Bible. Its ministry is motivated by the love of God. Its mission is to preach the gospel of Jesus Christ and to meet human needs in His name without discrimination.Position Summary: The Director of Compliance is responsible for developing, implementing, and overseeing the organization's compliance to ensure adherence to federal, state, and local regulations, accreditation standards, and internal policies. This role ensures that the facility's operations meet all clinical, ethical, and legal requirements, protecting clients, staff, and the organization's reputation.Essential Responsibilities:Develop, implement, and maintain a comprehensive compliance program in line with federal (HIPAA, CARF), state, and local regulations at all 3 Harbor Light sites.Draft, review, and update organizational policies and procedures to ensure they reflect current regulations and best practices.Oversee all accreditation processes (e.g., CARF and others as applicable) and serve as the primary point of contact for all related matters.Establish and maintain a hard stop EMR system to ensure record compliance.Serve as the primary point of contact for regulatory agencies, auditors, and accrediting bodies (CARF, state licensing boards).Conduct internal audits of clinical and operational practices, including documentation, billing, patient records, and medication handling.Track corrective actions and follow-up to ensure compliance gaps are addressed promptly.Prepare for and coordinate external audits, site visits, and accreditation surveys.Develop and deliver staff training programs on compliance, ethics, patient rights, and confidentiality.Provide ongoing education about regulatory updates and emerging compliance issues.Coordinates staff training on quality standards, documentation best practices, and regulatory compliance to maintain a culture of continuous improvement and service excellence.Investigate compliance-related incidents, breaches, or complaints; recommend corrective action.Oversee reporting requirements for adverse events, sentinel events, and mandated disclosures.Oversee the regulatory agencies database and input data for the application process and monitor the data input for citation clearance.Implements corrective action plans in response to internal audits, licensing visits, accreditation reviews, or other quality findings.Routinely monitors corrective measures to ensure ongoing compliance.Regularly evaluates service delivery against contractual obligations to ensure full compliance with finding requirements. Identify and address any discrepancies in performance.Maintain up-to-date knowledge of regulatory developments and emerging trends in behavioral health and homelessness to ensure organizational compliance and service relevance.Designs, implements, and takes leadership of the command center during any survey activity.Collaborate with clinical leadership to mitigate risk and improve patient safety.Collect and analyze compliance data, prepare reports for the Executive Director, Quality Assurance Committee, Divisional Finance Board (DFB).Monitor trends in compliance, patient care outcomes, and regulatory changes to proactively adjust organizational practices.Qualifications:Education/Experience:A master's degree in business or health/human services field, Licensed Registered Nurse, or bachelor's degree with equivalent experience.Minimum of seven years of experience in the SUD/Behavioral Health sector.Minimum of two years of management experience in the SUD/Behavioral Health sector.Three to five years of compliance background in SUD/Behavioral Health preferred.Possess a working knowledge of addiction recovery.Valid Michigan Chauffeur License and approved by The Salvation Army MVR.TB. test, police clearance, and MDOC LEIN clearance required.Skills, Knowledge & Abilities:Good communication skills.Computer Skills:Advanced Microsoft Office 365 skills.Certificates and Licenses:Complete Safe from Harm training, and keep current as needed.Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.Average Daily Physical RequirementsFrequencyWork in stationary positionMore than 5 hoursMove about work areaMore than 5 hoursUse hands/fingers to handle or feelMore than 5 hoursReach with hands and arms2 to 5 hoursClimb (stairs/ladders) or balanceNoneBend, stoop, kneel, crouch, or crawlNoneCommunicate with othersMore than 5 hoursDetect flavors or smellsNoneMove objects up to 30 poundsLess than 2 hoursVisual acuityMore than 5 hoursRead and understand written wordMore than 5 hoursDrive or travel2 to 5 hoursWork Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.Average Daily Environmental ConditionsFrequencyEnvironment: No exposure to extreme heat, cold, noise, chemicals or hazardous equipment.NoneMedical Environment: Exposure to body fluids, radiation, medical equipment, solvents or chemicals.NoneNoise: Exposure to constant or intermittent extreme sounds.NoneTemperature: Exposure to extreme heat or cold either indoors or outside.NoneIn addition:COMMUNICATION: Ability to effectively receive and express ideas, both written and verbal; using clear and concise vocabulary and active listening skills.DECISION MAKING: Ability to select and commit to an effective course of action by understanding issues, comparing solutions and drawing conclusions to resolve problems.INITIATIVE: Ability to act promptly and take steps to solve or settle an issue proactively.LEADERSHIP: Ability to motivate and guide others to ensure performance in accordance with clear expectations and goals; providing timely guidance and feedback.PROBLEM SOLVING: Ability to