Casa Esperanza, Inc.
Associate Director of Compliance & Quality Improvement
Casa Esperanza, Inc., Malden, Massachusetts, us, 02148
Associate Director of Compliance & Quality Improvement
Casa Esperanza, Inc. is a bilingual/bicultural behavioral health treatment provider serving Boston and the Merrimack Valley. Our mission is to empower individuals and families to recover from addiction, trauma, mental illness, and other chronic medical conditions; overcome homelessness and discrimination; and achieve health and wellness through comprehensive, integrated care.
About the role TheAssociate Director of Compliance & Quality Improvementis a key leadership role responsible for designing, implementing, and managing a comprehensive compliance program across the behavioral health system. Reporting directly to theDirector of Clinical Operations & Network Strategy, this position ensures that all organizational activities, clinical operations, and business practices adhere to federal, state, and payer regulations, internal policies, and ethical standards.
The Associate Director will establish and lead the compliance infrastructure—developing systems, policies, and processes that minimize organizational risk, ensure readiness for audits, and drive quality improvement. The role will require close collaboration with departments includingPayer Relations, Provider Relations, Practice Management, Quality, Human Resources, Clinical Operations, Finance, and othersto ensure a culture of compliance and accountability across the enterprise.
What you'll do
Compliance Program Leadership
Design, implement, and oversee the organization’sCompliance Department and comprehensive compliance program, ensuring alignment with regulatory requirements, accreditation standards, and organizational goals.
Develop, update, and enforce compliance policies and procedures covering clinical, operational, billing, privacy, and administrative activities.
Establish mechanisms forreporting, investigating, and resolving compliance concerns, ensuring timely and appropriate corrective actions and performance improvement projects.
Create and maintain acompliance governance structure, that includes regular reporting to the leadership teams in conjunction with the Director of Clinical/Medical Operations & Network Strategy & Development which provides compliance forecasting on a continuous basis
Monitor regulatory developments in behavioral health and ensure timely communication and implementation of necessary changes.
Regulatory Oversight & Risk Management
Oversee compliance with all applicable federal and state regulations, including HIPAA, CMS, Medicaid, Medicare, CARF, and other/payer-specific standards as needed
Develop arisk assessment frameworkto identify, prioritize, and mitigate potential areas of compliance vulnerability.
Conduct and manageinternal audits and monitoring activitiesto ensure accuracy and integrity in billing, documentation, clinical operations, and administrative practices.
Lead investigations into compliance violations, coordinate corrective actions, and ensure follow-up and documentation.
Serve as the organizational liaison for external audits, payer reviews, and regulatory inspections.
Prepare comprehensive compliance reports and risk analyses for executive leadership.
Program Management & Quality Initiatives
Establish and manage a structuredCompliance Program Management Office (PMO)for overseeing ongoing and ad hoc compliance and quality improvement initiatives.
Plan, lead, and trackorganization-wide projectsfocused on audit readiness, quality improvement, and risk reduction.
Collaborate with Clinical and Operations leadership to align quality and compliance initiatives with performance improvement goals.
Implement data-driven compliance dashboards and tracking systems for real-time visibility into key compliance indicators.
Partner with the Quality and Clinical Operations teams to ensure performance improvement activities support regulatory compliance and best practices.
Collaboration & Cross-Functional Engagement
With the collaboration of the Director, Clinical/Medical Operations & Network Strategy & Development work in close partnership with:
Payer Relations
to ensure adherence to payer contract requirements, credentialing standards, and utilization review expectations.
Provider Relations
to reinforce provider education, training, and compliance with documentation, coding, and clinical protocols.
Practice Management
to maintain compliant workflows, patient privacy standards, and operational efficiency.
Human Resources
to manage compliance training programs, employee onboarding education, and disciplinary processes when appropriate.
Finance & Billing Teams
to ensure claims integrity and compliance with reimbursement requirements.
Serve as a trusted compliance advisor to operational leaders, ensuring integration of compliance considerations in all decision-making processes.
Training, Education & Culture
Develop and implement acomprehensive compliance training and education programfor staff and leadership at all levels.
Promote a proactive culture of compliance, ethics, and transparency throughout the organization.
Provide ongoing guidance and mentorship to department leaders to strengthen internal accountability and compliance ownership.
Qualifications Education:
Bachelor’s and/or Master’s degree in Healthcare Administration, or related field preferred but not required if equivalent experience standards are met
Required Experience:
Minimum
4 - 5 years of experience
in healthcare compliance, preferably within behavioral health, mental health, or integrated care systems.
Demonstrated experiencebuilding and leading compliance programsor departments.
Strong background inpayer compliance, audits, and risk mitigation.
Knowledge of federal and state healthcare regulations, including HIPAA, CMS, OIG, and behavioral health licensing standards.
Certifications (Preferred):
Certified in Healthcare Compliance (CHC) or Certified Professional Compliance Officer (CPCO) or willingness to obtain certification within one year of employment
Proven ability to manage complex compliance initiatives and cross-departmental collaboration.
Strong analytical, investigative, and project management skills.
Exceptional written and verbal communication skills for training, policy development, and leadership reporting.
Strategic thinker with the ability to operationalize compliance frameworks into scalable systems.
Reports To: Director of Clinical Operations & Network Strategy
Hybrid or on-site role depending on organizational needs.
Moderate travel to clinics, regional offices, or audit sites as needed.
Schedule
Full-Time, 40 hours per week, Monday-Friday, 9-5pm
What we offer:
Holiday Pay (12 days per year + 1 floating holiday)
Paid Time Off (PTO) - 18 days year one, 20.5 days at year 2, 23 days at year 5
Sick Pay - 10 paid days per year
Long/ShortTerm Disability
Paid by Company Life Insurance
Health Reimbursement Arrangement (HRA)
ComPsych Guidance Resources - EAP
Educational Opportunities
Employee Ticket at Work (Discounts for Entertainment, travel, movies; etc.)
Increased Salary for Credentials
and more....
Physical & Mental Requirements While performing the duties of this job, the employee is regularly required to walk, stoop, kneel, crouch, or crawl and talk or hear. The employee must occasionally lift and/or move up to 20 pounds. Specific vision abilities required by this job include distance vision, peripheral vision, and depth perception.
At Casa Esperanza, Inc., the health and safety of our people is our number one priority. That’s why all offers of employment are contingent on the candidate showing proof of being fully vaccinated against COVID-19 (currently one dose of the Johnson & Johnson vaccine or two doses of the Pfizer or Moderna vaccine and boosted, when eligible) to pass the pre-employment requirements. Individuals with medical issues or religious beliefs that prevent them from getting the vaccine may request an exemption from the vaccine requirement.
Casa Esperanza, Inc. values its diverse workplace and encourages women, people of color, LGBTQIA+ individuals, people with disabilities, members of ethnic minorities, foreign-born residents, older members of society, and others from minority groups and diverse backgrounds to apply.
We recruit, hire, employ, train, promote, and compensate individuals based on job-related qualifications and abilities. Casa Esperanza, Inc. also has a longstanding policy of providing a work environment that respects the dignity and worth of each individual and is free from all forms of employment discrimination, including harassment, because of race, color, sex, gender, age, religion or religious creed, national origin, ancestry, citizenship, marital status, sexual orientation, gender identity, gender expression, genetic information, physical or mental disability, military or veteran status, or any other characteristic protected by law. All employees, interns, volunteers, and contractors of Casa Esperanza, Inc. are responsible for maintaining a work culture free from discrimination and harassment by treating others with kindness and respect.
Casa Esperanza, Inc. also provides reasonable accommodation to qualified individuals with disabilities or based on a sincerely held religious belief, in accordance with applicable laws. If you need to inquire about an accommodation or need assistance with completing the application process, please email hr@casaesperanza.org.
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About the role TheAssociate Director of Compliance & Quality Improvementis a key leadership role responsible for designing, implementing, and managing a comprehensive compliance program across the behavioral health system. Reporting directly to theDirector of Clinical Operations & Network Strategy, this position ensures that all organizational activities, clinical operations, and business practices adhere to federal, state, and payer regulations, internal policies, and ethical standards.
The Associate Director will establish and lead the compliance infrastructure—developing systems, policies, and processes that minimize organizational risk, ensure readiness for audits, and drive quality improvement. The role will require close collaboration with departments includingPayer Relations, Provider Relations, Practice Management, Quality, Human Resources, Clinical Operations, Finance, and othersto ensure a culture of compliance and accountability across the enterprise.
What you'll do
Compliance Program Leadership
Design, implement, and oversee the organization’sCompliance Department and comprehensive compliance program, ensuring alignment with regulatory requirements, accreditation standards, and organizational goals.
Develop, update, and enforce compliance policies and procedures covering clinical, operational, billing, privacy, and administrative activities.
Establish mechanisms forreporting, investigating, and resolving compliance concerns, ensuring timely and appropriate corrective actions and performance improvement projects.
Create and maintain acompliance governance structure, that includes regular reporting to the leadership teams in conjunction with the Director of Clinical/Medical Operations & Network Strategy & Development which provides compliance forecasting on a continuous basis
Monitor regulatory developments in behavioral health and ensure timely communication and implementation of necessary changes.
Regulatory Oversight & Risk Management
Oversee compliance with all applicable federal and state regulations, including HIPAA, CMS, Medicaid, Medicare, CARF, and other/payer-specific standards as needed
Develop arisk assessment frameworkto identify, prioritize, and mitigate potential areas of compliance vulnerability.
Conduct and manageinternal audits and monitoring activitiesto ensure accuracy and integrity in billing, documentation, clinical operations, and administrative practices.
Lead investigations into compliance violations, coordinate corrective actions, and ensure follow-up and documentation.
Serve as the organizational liaison for external audits, payer reviews, and regulatory inspections.
Prepare comprehensive compliance reports and risk analyses for executive leadership.
Program Management & Quality Initiatives
Establish and manage a structuredCompliance Program Management Office (PMO)for overseeing ongoing and ad hoc compliance and quality improvement initiatives.
Plan, lead, and trackorganization-wide projectsfocused on audit readiness, quality improvement, and risk reduction.
Collaborate with Clinical and Operations leadership to align quality and compliance initiatives with performance improvement goals.
Implement data-driven compliance dashboards and tracking systems for real-time visibility into key compliance indicators.
Partner with the Quality and Clinical Operations teams to ensure performance improvement activities support regulatory compliance and best practices.
Collaboration & Cross-Functional Engagement
With the collaboration of the Director, Clinical/Medical Operations & Network Strategy & Development work in close partnership with:
Payer Relations
to ensure adherence to payer contract requirements, credentialing standards, and utilization review expectations.
Provider Relations
to reinforce provider education, training, and compliance with documentation, coding, and clinical protocols.
Practice Management
to maintain compliant workflows, patient privacy standards, and operational efficiency.
Human Resources
to manage compliance training programs, employee onboarding education, and disciplinary processes when appropriate.
Finance & Billing Teams
to ensure claims integrity and compliance with reimbursement requirements.
Serve as a trusted compliance advisor to operational leaders, ensuring integration of compliance considerations in all decision-making processes.
Training, Education & Culture
Develop and implement acomprehensive compliance training and education programfor staff and leadership at all levels.
Promote a proactive culture of compliance, ethics, and transparency throughout the organization.
Provide ongoing guidance and mentorship to department leaders to strengthen internal accountability and compliance ownership.
Qualifications Education:
Bachelor’s and/or Master’s degree in Healthcare Administration, or related field preferred but not required if equivalent experience standards are met
Required Experience:
Minimum
4 - 5 years of experience
in healthcare compliance, preferably within behavioral health, mental health, or integrated care systems.
Demonstrated experiencebuilding and leading compliance programsor departments.
Strong background inpayer compliance, audits, and risk mitigation.
Knowledge of federal and state healthcare regulations, including HIPAA, CMS, OIG, and behavioral health licensing standards.
Certifications (Preferred):
Certified in Healthcare Compliance (CHC) or Certified Professional Compliance Officer (CPCO) or willingness to obtain certification within one year of employment
Proven ability to manage complex compliance initiatives and cross-departmental collaboration.
Strong analytical, investigative, and project management skills.
Exceptional written and verbal communication skills for training, policy development, and leadership reporting.
Strategic thinker with the ability to operationalize compliance frameworks into scalable systems.
Reports To: Director of Clinical Operations & Network Strategy
Hybrid or on-site role depending on organizational needs.
Moderate travel to clinics, regional offices, or audit sites as needed.
Schedule
Full-Time, 40 hours per week, Monday-Friday, 9-5pm
What we offer:
Holiday Pay (12 days per year + 1 floating holiday)
Paid Time Off (PTO) - 18 days year one, 20.5 days at year 2, 23 days at year 5
Sick Pay - 10 paid days per year
Long/ShortTerm Disability
Paid by Company Life Insurance
Health Reimbursement Arrangement (HRA)
ComPsych Guidance Resources - EAP
Educational Opportunities
Employee Ticket at Work (Discounts for Entertainment, travel, movies; etc.)
Increased Salary for Credentials
and more....
Physical & Mental Requirements While performing the duties of this job, the employee is regularly required to walk, stoop, kneel, crouch, or crawl and talk or hear. The employee must occasionally lift and/or move up to 20 pounds. Specific vision abilities required by this job include distance vision, peripheral vision, and depth perception.
At Casa Esperanza, Inc., the health and safety of our people is our number one priority. That’s why all offers of employment are contingent on the candidate showing proof of being fully vaccinated against COVID-19 (currently one dose of the Johnson & Johnson vaccine or two doses of the Pfizer or Moderna vaccine and boosted, when eligible) to pass the pre-employment requirements. Individuals with medical issues or religious beliefs that prevent them from getting the vaccine may request an exemption from the vaccine requirement.
Casa Esperanza, Inc. values its diverse workplace and encourages women, people of color, LGBTQIA+ individuals, people with disabilities, members of ethnic minorities, foreign-born residents, older members of society, and others from minority groups and diverse backgrounds to apply.
We recruit, hire, employ, train, promote, and compensate individuals based on job-related qualifications and abilities. Casa Esperanza, Inc. also has a longstanding policy of providing a work environment that respects the dignity and worth of each individual and is free from all forms of employment discrimination, including harassment, because of race, color, sex, gender, age, religion or religious creed, national origin, ancestry, citizenship, marital status, sexual orientation, gender identity, gender expression, genetic information, physical or mental disability, military or veteran status, or any other characteristic protected by law. All employees, interns, volunteers, and contractors of Casa Esperanza, Inc. are responsible for maintaining a work culture free from discrimination and harassment by treating others with kindness and respect.
Casa Esperanza, Inc. also provides reasonable accommodation to qualified individuals with disabilities or based on a sincerely held religious belief, in accordance with applicable laws. If you need to inquire about an accommodation or need assistance with completing the application process, please email hr@casaesperanza.org.
#J-18808-Ljbffr