Compliance Officer I

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The Massachusetts Department of Public Health is seeking a Compliance Officer I to play an essential role in promoting regulatory compliance, patient rights, quality, and accountability within a hospital setting. Reporting to the Chief Clinical Officer, you will help ensure hospital policies, procedures, and practices align with federal and state requirements, including applicable CMS Conditions of Participation, Joint Commission standards, MassHealth regulations, and other governing requirements. This is an excellent opportunity for a detail-oriented professional who enjoys investigative work, analyzing information, identifying risks, and helping healthcare organizations strengthen their practices.

In this role, you will work across departments and collaborate with clinical, administrative, and senior leadership teams on compliance monitoring, audits, grievances, patient rights, corrective action planning, and quality and patient safety initiatives. You will have the opportunity to participate in hospital committees and translate audit findings and regulatory requirements into practical recommendations that support safe, compliant, and patient-centered care. Candidates with experience in regulatory, investigative, compliance, healthcare, or related work are encouraged to apply.

This is a 37.5-hour position, working Mon-Fri, 8:30-4:30. The days off are Saturday and Sunday.

Duties and Responsibilities (these duties are a general summary and not all inclusive):

• Review and audit hospital policies, procedures, and practices to ensure compliance with applicable federal and state laws, regulations, Joint Commission standards, and CMS Conditions of Participation.
• Conduct internal compliance monitoring and audits of hospital services, including reviews related to MassHealth requirements, quality, medical necessity, and regulatory standards.
• Investigate compliance concerns, patient complaints, and grievances, and coordinate appropriate resolution and implementation of corrective actions.
• Monitor compliance with patient rights and responsibilities, including informed consent, interpreter and translator services, and admission and discharge requirements.
• Support compliance with protective services requirements, including abuse and neglect reporting timelines and resolution.
• Prepare detailed reports, presentations, findings, and recommendations regarding compliance, audit results, and identified areas of risk.
• Collaborate with department leaders, Patient Advocacy, Social Work, Behavioral Health, and other stakeholders to promote adherence to patient rights, policies, and regulatory requirements.
• Participate actively in hospital committees, councils, task forces, and quality and patient safety initiatives, including reviewing committee deliverables for compliance.
• Coordinate medical records submissions and related documentation for MassHealth reviews and other regulatory or compliance activities.
• Assist senior leadership with corrective action planning, risk mitigation, and implementation of compliance improvements, while performing related duties as assigned.

Required Qualifications:

• Knowledge of report-writing principles and the ability to communicate information clearly, concisely, and logically in written form.
• Ability to gather, investigate, evaluate, and accurately document information through interviews, observation, records review, and other investigative techniques.
• Ability to analyze data and information, draw appropriate conclusions, and develop sound recommendations based on findings.
• Ability to understand, interpret, explain, and apply laws, regulations, policies, procedures, standards, specifications, and guidelines governing assigned activities.
• Ability to prepare accurate reports and maintain organized and complete records in accordance with established procedures.
• Ability to exercise sound judgment and discretion, including when handling confidential information and addressing sensitive or complex situations.
• Strong interpersonal and communication skills, including the ability to establish rapport and maintain effective working relationships with individuals from diverse backgrounds.
• Ability to communicate instructions and information clearly and effectively, both orally and in writing, and to follow written and verbal directions.
• Ability to remain calm and effective in stressful or emergency situations, adapt to varied work environments, and work independently.
• Ability to motivate and work collaboratively with others; knowledge of agency forms and investigative techniques may be acquired on the job.

Preferred Qualifications:

• Experience in healthcare compliance, regulatory affairs, quality assurance, risk management, or a related field.
• Experience interpreting and applying federal and state healthcare laws, regulations, standards, and accreditation requirements.
• Familiarity with CMS Conditions of Participation, Joint Commission standards, MassHealth regulations, and other healthcare regulatory requirements.
• Experience conducting compliance audits, investigations, monitoring activities, or internal reviews and developing corrective action recommendations.
• Experience working with patient rights, grievances, complaints, informed consent, abuse and neglect reporting, or patient advocacy processes.
• Experience analyzing medical records, clinical documentation, or other healthcare records for regulatory compliance, quality, or medical necessity.
• Strong written and verbal communication skills, with experience preparing compliance reports, presentations, audit findings, or recommendations for leadership.
• Experience collaborating effectively with clinical, administrative, quality, legal, behavioral health, social work, or other multidisciplinary teams.
• Demonstrated ability to exercise sound judgment, maintain confidentiality, identify regulatory risks, and recommend practical solutions in a complex healthcare environment.

About the Department of Public Health:

The mission of the Massachusetts Department of Public Health (DPH) is to prevent illness, injury, and premature death, to assure access to high quality public health and health care services, and to promote wellness and health equity for all people in the Commonwealth.

We envision a Commonwealth in which all people enjoy optimal health. Massachusetts ranks among the healthiest states according to comparative analyses, but we face numerous challenges, including chronic and infectious disease, substance abuse, violence, preventable hospitalizations, and health disparities.

DPH coordinates programs and policies to address specific diseases and conditions and offer services to address the needs of vulnerable populations. We also develop, implement, promote, and enforce regulations and policies to assure that the conditions under which people live are most conducive to health and enable people to make healthy choices for themselves and their families. We license health professionals, healthcare facilities and a variety of businesses that impact public health. We operate the state laboratory and four public health hospitals. We monitor health status and manage vital records including births, marriages and deaths. We educate people about public health issues and work closely with local boards of health and community partners to identify and solve public health problems.

More information can be found at: MA Department of Public Health

Pre-Offer Process:

A criminal background check will be completed on the recommended candidate as required by the regulations set forth by the Executive Office of Health and Human Services prior to the candidate being hired. For more information, please visit http://www.mass.gov/hhs/cori

Education, licensure and certifications will be verified in accordance with the Human Resources Division's Hiring Guidelines

Education and license/certification information provided by the selected candidate(s) is subject to the Massachusetts Public Records Law and may be published on the Commonwealth's website.

ADA Reasonable Accommodation:

If you require a reasonable accommodation with the application/interview process, please contact us at: EOHHS Candidate ADA Requests.

For questions regarding this requisition, please contact Executive Office of Health and Human Services, Human Resources at 1-800- 510-4122 Ext. # 4.

'',''!*!

The Massachusetts Department of Public Health is seeking a Compliance Officer I to play an essential role in promoting regulatory compliance, patient rights, quality, and accountability within a hospital setting. Reporting to the Chief Clinical Officer, you will help ensure hospital policies, procedures, and practices align with federal and state requirements, including applicable CMS Conditions of Participation, Joint Commission standards, MassHealth regulations, and other governing requirements. This is an excellent opportunity for a detail-oriented professional who enjoys investigative work, analyzing information, identifying risks, and helping healthcare organizations strengthen their practices.

In this role, you will work across departments and collaborate with clinical, administrative, and senior leadership teams on compliance monitoring, audits, grievances, patient rights, corrective action planning, and quality and patient safety initiatives. You will have the opportunity to participate in hospital committees and translate audit findings and regulatory requirements into practical recommendations that support safe, compliant, and patient-centered care. Candidates with experience in regulatory, investigative, compliance, healthcare, or related work are encouraged to apply.

This is a 37.5-hour position, working Mon-Fri, 8:30-4:30. The days off are Saturday and Sunday.

Duties and Responsibilities (these duties are a general summary and not all inclusive):

• Review and audit hospital policies, procedures, and practices to ensure compliance with applicable federal and state laws, regulations, Joint Commission standards, and CMS Conditions of Participation.
• Conduct internal compliance monitoring and audits of hospital services, including reviews related to MassHealth requirements, quality, medical necessity, and regulatory standards.
• Investigate compliance concerns, patient complaints, and grievances, and coordinate appropriate resolution and implementation of corrective actions.
• Monitor compliance with patient rights and responsibilities, including informed consent, interpreter and translator services, and admission and discharge requirements.
• Support compliance with protective services requirements, including abuse and neglect reporting timelines and resolution.
• Prepare detailed reports, presentations, findings, and recommendations regarding compliance, audit results, and identified areas of risk.
• Collaborate with department leaders, Patient Advocacy, Social Work, Behavioral Health, and other stakeholders to promote adherence to patient rights, policies, and regulatory requirements.
• Participate actively in hospital committees, councils, task forces, and quality and patient safety initiatives, including reviewing committee deliverables for compliance.
• Coordinate medical records submissions and related documentation for MassHealth reviews and other regulatory or compliance activities.
• Assist senior leadership with corrective action planning, risk mitigation, and implementation of compliance improvements, while performing related duties as assigned.

Required Qualifications:

• Knowledge of report-writing principles and the ability to communicate information clearly, concisely, and logically in written form.
• Ability to gather, investigate, evaluate, and accurately document information through interviews, observation, records review, and other investigative techniques.
• Ability to analyze data and information, draw appropriate conclusions, and develop sound recommendations based on findings.
• Ability to understand, interpret, explain, and apply laws, regulations, policies, procedures, standards, specifications, and guidelines governing assigned activities.
• Ability to prepare accurate reports and maintain organized and complete records in accordance with established procedures.
• Ability to exercise sound judgment and discretion, including when handling confidential information and addressing sensitive or complex situations.
• Strong interpersonal and communication skills, including the ability to establish rapport and maintain effective working relationships with individuals from diverse backgrounds.
• Ability to communicate instructions and information clearly and effectively, both orally and in writing, and to follow written and verbal directions.
• Ability to remain calm and effective in stressful or emergency situations, adapt to varied work environments, and work independently.
• Ability to motivate and work collaboratively with others; knowledge of agency forms and investigative techniques may be acquired on the job.

Preferred Qualifications:

• Experience in healthcare compliance, regulatory affairs, quality assurance, risk management, or a related field.
• Experience interpreting and applying federal and state healthcare laws, regulations, standards, and accreditation requirements.
• Familiarity with CMS Conditions of Participation, Joint Commission standards, MassHealth regulations, and other healthcare regulatory requirements.
• Experience conducting compliance audits, investigations, monitoring activities, or internal reviews and developing corrective action recommendations.
• Experience working with patient rights, grievances, complaints, informed consent, abuse and neglect reporting, or patient advocacy processes.
• Experience analyzing medical records, clinical documentation, or other healthcare records for regulatory compliance, quality, or medical necessity.
• Strong written and verbal communication skills, with experience preparing compliance reports, presentations, audit findings, or recommendations for leadership.
• Experience collaborating effectively with clinical, administrative, quality, legal, behavioral health, social work, or other multidisciplinary teams.
• Demonstrated ability to exercise sound judgment, maintain confidentiality, identify regulatory risks, and recommend practical solutions in a complex healthcare environment.

About the Department of Public Health:

The mission of the Massachusetts Department of Public Health (DPH) is to prevent illness, injury, and premature death, to assure access to high quality public health and health care services, and to promote wellness and health equity for all people in the Commonwealth.

We envision a Commonwealth in which all people enjoy optimal health. Massachusetts ranks among the healthiest states according to comparative analyses, but we face numerous challenges, including chronic and infectious disease, substance abuse, violence, preventable hospitalizations, and health disparities.

DPH coordinates programs and policies to address specific diseases and conditions and offer services to address the needs of vulnerable populations. We also develop, implement, promote, and enforce regulations and policies to assure that the conditions under which people live are most conducive to health and enable people to make healthy choices for themselves and their families. We license health professionals, healthcare facilities and a variety of businesses that impact public health. We operate the state laboratory and four public health hospitals. We monitor health status and manage vital records including births, marriages and deaths. We educate people about public health issues and work closely with local boards of health and community partners to identify and solve public health problems.

More information can be found at: MA Department of Public Health

Pre-Offer Process:

A criminal background check will be completed on the recommended candidate as required by the regulations set forth by the Executive Office of Health and Human Services prior to the candidate being hired. For more information, please visit http://www.mass.gov/hhs/cori

Education, licensure and certifications will be verified in accordance with the Human Resources Division's Hiring Guidelines

Education and license/certification information provided by the selected candidate(s) is subject to the Massachusetts Public Records Law and may be published on the Commonwealth's website.

ADA Reasonable Accommodation:

If you require a reasonable accommodation with the application/interview process, please contact us at: EOHHS Candidate ADA Requests.

For questions regarding this requisition, please contact Executive Office of Health and Human Services, Human Resources at 1-800- 510-4122 Ext. # 4.

'',''!*!

First consideration will be given to those applicants that apply within the first 14 days.

Minimum Entrance Requirements: Applicants must have at least (A) two years of full-time, or equivalent part-time, experience in investigatory, law enforcement or regulatory administration work, or (B) and equivalent combination of the required experience and the substitutions below.

Substitutions:

A Bachelor''s or higher degree may be substituted for the required experience.*

• Education toward such a degree will be prorated on the basis of the proportion of the requirements actually completed.

Salary placement is determined by a combination of factors, including the candidate's years of directly related experience and education, and alignment with our internal compensation structure as set forth by the Human Resources Division's Hiring Guidelines. For all bargaining unit positions (non-management), compensation is subject to the salary provisions outlined in the applicable collective bargaining agreement and will apply to placement within the appropriate salary range.

Comprehensive Benefits

When you embark on a career with the Commonwealth, you are offered an outstanding suite of employee benefits that add to the overall value of your compensation package. We take pride in providing a work experience that supports you, your loved ones, and your future.

Want the specifics? Explore our Employee Benefits and Rewards!

Title 101 CMR 23.00 ("Regulation") requires certain agency staff to have received the COVID-19 vaccination and Influenza vaccination, or have taken required mitigation measures, to prevent viral infection and transmission in State Hospitals and State Congregate Care Facilities. The Regulation applies to this position. Successful candidates will be required to acknowledge and attest to your vaccination status for both COVID-19 and Influenza.

An Equal Opportunity / Affirmative Action Employer. Females, minorities, veterans, and persons with disabilities are strongly encouraged to apply.

The Commonwealth is an Equal Opportunity Employer and does not discriminate on the basis of race, religion, color, sex, gender identity or expression, sexual orientation, age, disability, national origin, veteran status, or any other basis covered by appropriate law. Research suggests that qualified women, Black, Indigenous, and Persons of Color (BIPOC) may self-select out of opportunities if they don''t meet 100% of the job requirements. We encourage individuals who believe they have the skills necessary to thrive to apply for this role.

'',''!*!

First consideration will be given to those applicants that apply within the first 14 days.

Minimum Entrance Requirements: Applicants must have at least (A) two years of full-time, or equivalent part-time, experience in investigatory, law enforcement or regulatory administration work, or (B) and equivalent combination of the required experience and the substitutions below.

Substitutions:

A Bachelor''s or higher degree may be substituted for the required experience.*

• Education toward such a degree will be prorated on the basis of the proportion of the requirements actually completed.

Salary placement is determined by a combination of factors, including the candidate's years of directly related experience and education, and alignment with our internal compensation structure as set forth by the Human Resources Division's Hiring Guidelines. For all bargaining unit positions (non-management), compensation is subject to the salary provisions outlined in the applicable collective bargaining agreement and will apply to placement within the appropriate salary range.

Comprehensive Benefits

When you embark on a career with the Commonwealth, you are offered an outstanding suite of employee benefits that add to the overall value of your compensation package. We take pride in providing a work experience that supports you, your loved ones, and your future.

Want the specifics? Explore our Employee Benefits and Rewards!

Title 101 CMR 23.00 ("Regulation") requires certain agency staff to have received the COVID-19 vaccination and Influenza vaccination, or have taken required mitigation measures, to prevent viral infection and transmission in State Hospitals and State Congregate Care Facilities. The Regulation applies to this position. Successful candidates will be required to acknowledge and attest to your vaccination status for both COVID-19 and Influenza.

An Equal Opportunity / Affirmative Action Employer. Females, minorities, veterans, and persons with disabilities are strongly encouraged to apply.

The Commonwealth is an Equal Opportunity Employer and does not discriminate on the basis of race, religion, color, sex, gender identity or expression, sexual orientation, age, disability, national origin, veteran status, or any other basis covered by appropriate law. Research suggests that qualified women, Black, Indigenous, and Persons of Color (BIPOC) may self-select out of opportunities if they don''t meet 100% of the job requirements. We encourage individuals who believe they have the skills necessary to thrive to apply for this role.

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