Guidelight Health is a cutting-edge behavioral healthcare company dedicated to transforming lives through high-quality PHP (Partial Hospitalization Program) and IOP (Intensive Outpatient Program) services. As a newly launched organization, we are on a mission to redefine the behavioral health industry by delivering exceptional care, utilizing state-of-the-art facilities, and prioritizing the well-being of those we serve. At Guidelight Health, we are building a team of passionate, forward-thinking professionals who are eager to be part of this exciting journey to reshape mental health care. Join us in making a lasting impact!
Guidelight Health is a cutting-edge behavioral healthcare company dedicated to transforming lives through high-quality PHP (Partial Hospitalization Program) and IOP (Intensive Outpatient Program) services. As a newly launched organization, we are on a mission to redefine the behavioral health industry by delivering exceptional care, utilizing state-of-the-art facilities, and prioritizing the well-being of those we serve. At Guidelight Health, we are building a team of passionate, forward-thinking professionals who are eager to be part of this exciting journey to reshape mental health care. Join us in making a lasting impact!
Description:
Title: Compliance Manager
Reports to: Vice President of Compliance and Privacy
Department/Location: Remote
FLSA Status: Exempt
Guidelight is an Equal Opportunity Employer. We are passionate about fostering an environment where everyone, irrespective of their race, gender, sexual orientation, or background, feels valued and included.
Summary:
The Compliance Manager is responsible for overseeing and coordinating the organization's day-to-day compliance operations across corporate functions and all clinic locations. This role ensures adherence to applicable federal, state, and local regulations, CARF accreditation standards, Community Mental Health Center (CMHC) requirements, and all other regulatory and contractual obligations as directed by the Vice President, Compliance and Privacy Officer.
Working cross-functionally with corporate leadership, clinic leadership, and operational teams, the Compliance Manager supports regulatory readiness, accreditation maintenance, incident management, and complaints/grievance processes. The role plays a critical part in fostering a culture of compliance, accountability, client safety, and continuous improvement throughout the organization.
Core Competencies:
- Regulatory and accreditation expertise
- Risk assessment and problem-solving
- Cross-functional collaboration
- Clear and effective communication
- Ethical judgement and integrity
- Attention to detail and accountability
- Ability to manage multiple priorities independently
Responsibilities:
- Compliance Program Oversight and Regulatory Management
- Implement, monitor, and enforce the organization’s compliance program, policies, and procedures across all clinics and corporate departments.
- Serve as a subject matter resource to support the Vice President, Compliance and Privacy Officer by tracking and interpreting changes in federal, state, and local healthcare regulations and accreditation standards, and assisting with communication of impacts, requirements, and best practices to leadership and staff.
- Support compliance with CMHC requirements, licensing standards, payer requirements, and other applicable federal and state regulatory frameworks.
- Work closely with the Vice President, Compliance and Privacy Officer to support policy governance processes, ensuring organizational policies and procedures are current, compliant, consistently applied, and aligned with regulatory and accreditation standards.
- Accreditation & Survey Readiness (CARF and Other Standards)
- Coordinate and support ongoing CARF accreditation compliance activities, including preparation, documentation, mock surveys, and corrective action plans.
- Collaborate with clinic leaders and corporate teams to ensure sustained accreditation of readiness year-round.
- Participate in external audits, surveys, and regulatory inspections; respond to findings and oversee follow-up actions.
- Audits, Monitoring and Risk Management
- Conduct routine and targeted internal compliance audits and risk assessments across clinical and operational areas.
- Identify compliance gaps and risks; recommend and monitor corrective and preventive actions.
- Maintain accurate records of audits, monitoring activities, findings, and resolutions.
- Incident Management and Reporting
- Oversee the incident reporting process, ensuring timely intake, investigation, documentation, trending, and resolution of incidents
- Collaborate with clinical leadership, Quality, and Operations to address incidents and mitigate future risk.
- Ensure incidents are escalated, reported, and tracked in accordance with regulatory, accreditation, and organizational requirements.
- Client Complaints and Grievances
- Serves as the compliance oversight liaison for client complaints and grievance processes across all clinics, ensuring each clinic is managing its assigned process and response team.
- Ensure timely investigation, documentation, and resolution of complaints, in alignment with regulatory and accreditation standards related to client rights, grievances, and appeals.
- Monitor and analyze complaints and grievance trends, collaborating with leadership to identify areas for improvement and implement corrective strategies.
- Support clinics in maintaining accountability and consistency while respecting the designated ownership of each site.
- Client Safety & Quality Collaboration
- Partner closely with the Director of Quality to support client safety initiatives and quality improvement efforts.
- Assist in identifying systemic risks and implementing strategies to reduce harm and improve outcomes.
- Support integration of compliance and quality initiatives to meet regulatory and accreditation expectations.
- Training & Education
- Develop, implement, and track required compliance training programs including onboarding, annual training, and role-specific education.
- Educate staff and leadership on compliance expectations, policies, and regulatory updates.
- Monitor training completion and follow up on deficiencies.
- Reporting & Governance Support
- Develop and maintain compliance metrics, dashboards, and reports to assess program effectiveness.
- Prepare regular compliance reports to senior leadership, committees, and the Board as requested.
- Support compliance committee activities and documentation
Qualifications:
- Bachelor’s degree in healthcare administration, business, nursing, public health, or related field.
- Minimum of 3-5 years of compliance experience, preferably in behavioral health or CMHC setting.
- Demonstrated experience with CARF accreditation or similar healthcare accreditation standards.
- Strong working knowledge of healthcare regulations, including HIPAA, patient rights, incident reporting, and licensure requirements.
- Experience managing audits, incident investigations, complaints/grievances, and corrective action plans.
- Excellent organizational, analytical, communication, and interpersonal skills.
- Ability to manage sensitive and confidential information with discretion and professionalism.
