Director of Quality, Compliance & Education

Director of Quality, Compliance & Education

JOB SUMMARY

The Director of Quality, Compliance & Education is responsible for leading the hospice's compliance program, Quality Assurance and Performance Improvement (QAPI) program, and clinical education initiatives. This role ensures the organization operates in full regulatory compliance with federal, state, and accreditation standards while driving continuous quality improvement and fostering a culture of accountability, ethics, and ongoing staff development.

The Director oversees clinical education programs including staff orientation, ongoing competency development, and targeted training in collaboration with clinical leadership.

QUALIFICATIONS

1. Graduate of an approved school of nursing; currently licensed in the state(s) of practice preferred; or a qualified healthcare professional with relevant experience.
2. Minimum of five (5) years of healthcare experience, preferably in hospice or home health.
3. Minimum of two (2) years of experience in quality, compliance, or QAPI leadership preferred.
4. Knowledge of CMS hospice Conditions of Participation (CoPs), state regulations, and accreditation standards.
5. Demonstrated leadership, analytical, and organizational skills.
6. Ability to exercise independent judgment and manage multiple priorities.
7. Strong communication skills with the ability to educate, influence, and collaborate across disciplines.

CORE RESPONSIBILITIES

1. Compliance Oversight

• Maintain current knowledge of hospice regulations and ensure organizational compliance
• Develop, review, and update policies and procedures at least annually
• Lead internal audits (clinical, billing, documentation, eligibility)
• Investigate compliance risks, complaints, and incidents
• Oversee corrective action plans (CAPs) through resolution
• Ensure continuous survey readiness and coordinate responses to deficiencies
• Maintain compliance program elements including reporting mechanisms and non-retaliation practices

1. Quality & Performance Improvement (QAPI)

• Lead and coordinate the hospice-wide QAPI program
• Develop and monitor quality metrics (e.g., CAHPS, HOPE, hospitalizations, live discharges)
• Ensure data collection, aggregation, analysis, and reporting
• Facilitate QAPI committee meetings and maintain documentation
• Identify trends and implement performance improvement projects (PIPs)
• Evaluate effectiveness of interventions and adjust strategies as needed

1. Clinical Education & Staff Development

• Oversee and ensure effective orientation of all new clinical and non-clinical staff
• Develop and implement ongoing education programs in collaboration with clinical leadership (e.g., DCS, Medical Director)
• Ensure completion of required onboarding and annual training
• Provide targeted education based on:
  • Audit findings
  • Quality trends
  • Regulatory updates
• Ensure competency validation and documentation of staff training
• Serve as a resource for clinical and compliance-related education needs
• Promote a culture of continuous learning and accountability

1. Data Management & Reporting

• Ensure accuracy, integrity, and timeliness of all data submissions
• Maintain dashboards and reports for leadership review
• Translate data into actionable insights for operational improvement
• Submit required regulatory reports and maintain documentation for survey readiness

1. Audit & Risk Management

• Conduct and oversee routine chart audits and compliance reviews
• Monitor high-risk areas including eligibility, documentation, and billing
• Track audit results and trends
• Report findings with actionable recommendations
• Ensure follow-up and resolution of identified risks

1. Survey Readiness

• Maintain continuous readiness for regulatory and accreditation surveys
• Conduct mock surveys and tracer activities
• Ensure staff preparedness and documentation compliance
• Coordinate and oversee plans of correction when needed

1. Leadership & Collaboration

• Collaborate with Administrator, Director of Clinical Services, Medical Director, and leadership team
• Communicate quality and compliance risks promptly and clearly
• Balance regulatory enforcement with operational partnership
• Serve as a role model for professionalism, ethics, and performance

1. Documentation & Accountability

• Maintain organized records of:
  • Audits
  • QAPI activities
  • Education and training logs
  • Compliance investigations
• Ensure documentation meets regulatory standards and is survey-ready
• Meet all deadlines for reporting and program requirements

1. Program Oversight & Strategic Planning

• Conduct annual compliance risk assessments
• Develop annual audit and education plans
• Evaluate effectiveness of QAPI and compliance programs
• Lead emergency preparedness compliance activities and annual requirements

1. Professional Expectations

• Demonstrate integrity, confidentiality, and objectivity
• Maintain current knowledge of regulatory and industry changes
• Promote ethical behavior and a culture of accountability
• Maintain a proactive, solutions-oriented approach

WORKING ENVIRONMENT

Works primarily indoors in an office and clinical environment with occasional field or onsite visits as needed.

JOB RELATIONSHIPS

• Supervised by: Executive Director / Governing Body
• Supervises: QAPI Committee, Education functions, and may oversee compliance/quality staff

RISK EXPOSURE

Low to moderate risk

PHYSICAL REQUIREMENTS

Ability to:

• Sit, stand, and work for extended periods
• Perform moderate lifting if necessary
• Participate in physical activity as required
• Bend, lift, and move as needed in a clinical environment