Compliance Officer-Behavioral Health

Compliance Officer - Behavioral Health & Substance Use Treatment

Company: The Wave International / The Wave of North Florida Location: Clearwater, Florida Employment Type: Full-Time (Hybrid)

If you are an experienced healthcare compliance professional passionate about accreditation readiness, quality improvement, risk management, and behavioral healthcare excellence, we encourage you to apply and become a valued member of our leadership team.

The Compliance Officer will primarily work from our Clearwater location with flexibility for remote work when operationally appropriate. Periodic travel between company facilities will be required to conduct reviews, staff education, monitoring activities, and operational assessments. Occasional availability outside normal business hours may be necessary to support inspections, investigations, regulatory matters, accreditation activities, or organizational needs.

The Compliance Officer will serve as a trusted resource to executive leadership and operational teams, ensuring that organizational practices align with regulatory requirements while supporting exceptional patient care, ethical operations, and continuous organizational improvement.

We are looking for a professional who can identify potential risks before they become deficiencies, implement practical solutions, strengthen accountability, and foster a culture of ongoing readiness across all programs and locations.

Position Summary

The Compliance Officer is responsible for directing and monitoring the organization's compliance program, ensuring adherence to applicable federal, state, and accreditation standards governing behavioral health and substance use treatment services.

Working collaboratively with Executive Leadership, Medical Providers, Nursing, Clinical Directors, Human Resources, Operations, and Quality Management teams, this individual will support operational excellence by developing effective compliance systems, conducting monitoring activities, coordinating regulatory preparation efforts, and guiding departments through process improvement initiatives.

This position requires a strategic thinker who can effectively balance regulatory requirements with operational realities while maintaining a focus on quality outcomes, patient safety, and organizational integrity.

Cross-Functional Collaboration: Success in this role requires strong relationship-building skills and the ability to work effectively with stakeholders throughout the organization.

Key Responsibilities: Regulatory Compliance & Licensing

• Maintain organizational adherence to applicable federal, state, and local healthcare regulations.
• Monitor regulatory changes and communicate operational implications to leadership.
• Ensure compliance with AHCA and Florida DCF licensing requirements.
• Maintain organizational alignment with The Joint Commission accreditation standards.
• Evaluate business practices and identify opportunities to strengthen regulatory performance.
• Provide guidance to department leaders regarding regulatory obligations and industry best practices.
• Support implementation of operational changes necessary to maintain compliance

Accreditation & Survey Readiness: Lead preparation activities for Joint Commission surveys.

• Coordinate readiness efforts for AHCA inspections and DCF licensing reviews.
• Conduct mock surveys, tracers, and readiness assessments.
• Identify compliance vulnerabilities and areas requiring improvement.
• Maintain organized records and documentation required for inspections and accreditation reviews.
• Prepare leaders and staff for survey participation and interviews.
• Facilitate action planning related to survey observations and recommendations.
• Serve as a primary organizational liaison during surveys, inspections, audits, and regulatory visits.

Auditing & Monitoring

• Develop and maintain an ongoing compliance monitoring program.
• Perform chart reviews and healthcare documentation audits.
• Assess clinical and administrative records for completeness and regulatory alignment.
• Conduct environmental rounds and operational reviews.
• Evaluate compliance indicators and key performance measurements.
• Monitor adherence to organizational policies, procedures, and standards of practice.
• Prepare reports outlining findings, trends, recommendations, and follow-up actions.
• Verify implementation of corrective measures and sustained improvements.

Quality Improvement & Performance Excellence

• Participate in quality management and performance improvement initiatives.
• Analyze trends that may affect service quality, patient safety, or regulatory standing.
• Support development of improvement projects and performance goals.
• Conduct root cause analyses when appropriate.
• Collaborate with leadership to strengthen workflows and operational effectiveness.
• Evaluate outcomes of improvement efforts and recommend additional enhancements when necessary.

Corrective Action Planning

• Investigate compliance concerns, deficiencies, complaints, and regulatory findings.
• Develop and implement corrective action strategies.
• Coordinate follow-up activities with department leadership.
• Monitor action plans through completion.
• Validate effectiveness of remediation efforts.
• Develop preventive measures designed to reduce recurrence of identified issues.
• Assist with responses to regulatory agencies and accrediting bodies when required.

Policy & Procedure Management

• Draft, revise, and maintain organizational policies and procedures.
• Ensure documentation reflects current legal, regulatory, and accreditation requirements.
• Collaborate with operational leaders to implement policy changes.
• Maintain scheduled policy reviews and updates.
• Promote consistency across programs and facilities.
• Translate complex regulatory requirements into practical operational guidance.

Risk Management

• Identify and assess organizational risks related to compliance and operations.
• Review incidents, grievances, complaints, and reportable events.
• Recommend strategies to minimize regulatory and operational exposure.
• Participate in investigations related to compliance concerns.
• Support initiatives designed to strengthen patient safety and organizational accountability.
• Partner with leadership to develop sustainable risk reduction strategies.

Education & Staff Development

• Design and deliver compliance-related education programs.
• Provide regulatory updates to leaders and staff.
• Develop training materials and educational resources.
• Support orientation and ongoing workforce development activities.
• Promote ethical decision-making and accountability throughout the organization.
• Serve as an internal resource for compliance-related questions and guidance.

Areas of Oversight: The Compliance Officer will oversee activities related to:

• Clinical and administrative documentation
• Medical record integrity
• HIPAA and privacy requirements
• Confidentiality standards
• Medication management
• Controlled substance accountability
• Incident reporting and investigations
• Patient rights
• Staff training and competency requirements
• Personnel documentation
• Credentialing and privileging
• Infection prevention and control
• Environment of Care
• Emergency preparedness
• Discharge planning and documentation
• Records retention
• Licensing requirements
• Accreditation standards
• Quality initiatives
• Risk management programs
• Patient safety efforts
• Organizational performance monitoring

The Compliance Officer will regularly collaborate with:

• Executive Leadership
• Medical Providers
• Nursing Leadership
• Clinical Directors
• Program Administrators
• Human Resources
• Operations Teams
• Admissions Personnel
• Quality Management Staff
• Facility Leadership

Required Qualifications

• Bachelor's degree in Healthcare Administration, Nursing, Behavioral Health, Business Administration, Compliance, Public Health, or a related field.
• Leadership experience in healthcare compliance, quality improvement, accreditation, or risk management.
• Experience supporting detoxification and residential treatment programs.
• Experience conducting medical record and documentation reviews.
• Familiarity with electronic medical record (EMR/EHR) systems.
• Certified in Healthcare Compliance (CHC) or similar professional credential.
• Additional certifications related to healthcare quality, accreditation, patient safety, or risk management.
• Professional compliance experience within behavioral health, mental health, substance use disorder treatment, detoxification services, residential treatment, or a related healthcare environment.