Director Of Compliance

EDCare is seeking a Director of Compliance to provide leadership and oversight of our regulatory, accreditation, quality improvement, privacy, and risk management programs across all locations and levels of care. This role supports EDCare’s mission of delivering compassionate, evidence-based eating disorder treatment by promoting a culture of safety, ethical practice, patient rights, and continuous improvement. The Director of Compliance will partner with multidisciplinary teams and executive leadership to ensure EDCare remains compliant, survey-ready, and aligned with the highest standards of patient care.

Subject:                Job Description
Job Title:               Director of Compliance
Department:         Administrative
Programs:             All 
Supervisor:           CEO 
FLSA:                     Exempt, Salary
Date Reviewed:    June 2026

Summary of Major Functions:  

(I)    Maintain regulatory compliance with all accrediting agencies including, but not limited to, The Joint Commission, OSHA, Center of Medicare and Medicaid Services, the Center of Disease Control and Prevention, State and Federal Agencies.  

(II)    Works with multidisciplinary teams to ensure that Quality Improvement and Compliance Programs are well established and managed throughout the company. Is the company’s in-house authority on Quality and all Compliance matters. 

(III)    Responsible for the clinical and administrative systems, processes, and reports employed to detect, monitor, assess, mitigate, and prevent risks. The CCO is responsible for proactively and systematically safeguarding patient safety as well as EDCare’s assets, legal risks, accreditation, reimbursement levels, brand value, and community standing.

 (l) General Regulatory Compliance Duties:
1.    Subject matter expert on The Joint Commission (TJC) standards of Care.
2.    Subject matter expert with the Center of Medicaid and Medicare Services Regulations (CMS)
3.    Subject matter expert on Health Information Portability Accountability Act (HIPAA) regulations and develops and maintains the HIPAA compliant privacy program.
4.    Subject matter expert of Occupational Safety and Health Administration (OSHA) legal standards (in conjunction with Human Resources Manager)
5.    Understand licensing agencies, regulatory bodies, and state/federal laws in all states the company occupies.
6.    Provides recommendations regarding anti-kickback statute and Stark laws and regulations.
7.    Understands property compliance such as: zoning and Americans with Disabilities Act (ADA) among others.
8.    Subject matter expert on Behavioral Health Ethics. 

 (ll) General Quality Improvement and Compliance Program Duties:
1.    Establishes and maintains a company focus and continuous improvements to ensure a culture of safety.
2.    Directly responsible for the development, implementation, and execution of quality improvement initiatives across the organization.
3.    Develops internal company policies and procedures and ensures they are adhered to. 
4.    Develops process improvement plans for patient safety, quality or mandated regulatory initiatives, and patient satisfaction initiatives.
5.    Conducts routine scheduled and unscheduled internal reviews or audits to ensure that compliance procedures are followed. 
6.    Develops strategies and procedures for both obtaining and maintaining accreditations. 
7.    Ensures all departments are prepared for inspections and operating compliantly with Joint Commission, state, and regulatory agencies among others. 
8.    Manages and is responsible for on-site regulatory visits.
9.    Manages and develops policies/programs that encourage managers and employees to report suspected fraud and other improprieties, without fear of retaliation.
10.    Independently investigates and acts with diligence on matters related to compliance and ethics, reports the findings, and implements action plans to overcome them. 
11.    Investigates, reports, and remediates occurrences of data breaches.
12.    Ensures the protection of patients’ rights in accordance with federal and state laws.
13.    Provides strategic direction to the management team on quality and compliance.
14.    Prepares, analyzes, and presents clear and concise reports to the Board of Managers and the CEO.

(lll) Risk Assessment Duties:
1.    Conducts assessments to define and analyze possible risks. 
2.    Evaluates employees' risk awareness and provides training when necessary. 
3.    Reduces company risk by creating and implementing HIPAA-compliant procedures where needed to include audits, Business Associate Agreements and in conjunction with the COO, ensures that EDCare is properly protected.
4.    Prepares risk management action plans to decrease risk factors and communicates the plans to the COO and CEO.
5.    Executes approved risk management action plans on behalf of the company. 

Physical Demands and Environment:
Sitting frequently, standing occasionally, walking occasionally, talking frequently, hearing frequently, seeing constantly, reaching with arms and hands occasionally, crouching occasionally and using fingers intricately.  This position requires lifting/carrying up to 10 pounds occasionally.  

This position will require travel which will result in lifting, carrying, walking and navigating both car and airplane travel. Valid Driver’s License required. 

Environmental conditions of this job include but are NOT limited to:
99% inside, 99% normal temperature and 99% normal noise as expected in a medical office environment.

Nothing in this job description restricts management's right to assign or reassign duties and responsibilities to this job at any time.
 

Minimum Qualifications:
1.    Bachelor’s Degree Required.
2.    Minimum of 3 years as a manager of a major department.
3.    Understanding of TJC and other regulatory compliance requirements.
4.    Subject Matter Expert on The Joint Commission (TJC) standards of Care.
5.     Subject Matter Expert with the Center of Medicaid and Medicare Services Regulations (CMS).
6.     Subject Matter Expert on Health Information Portability Accountability Act (HIPAA) regulations.
7.    Subject Matter Expert on Occupational Safety and Health Administration (OSHA) legal standards.
8.    Subject Matter Expert on state licensing regulations for all locations. 
9.    Remains current on all job-related knowledge, skills, and on-going education, credentialing, and certification requirements, required by legal or regulatory bodies. 

Computer Skills:
1.    Minimum of intermediate skills in Microsoft Office suite.
2.    Must be able to efficiently learn and effectively work within an electronic medical records system.
3.    Must be able to efficiently learn and effectively work within various software products.