Director of Clinical Compliance – Hospice!

DIRECTOR OF CLINICAL COMPLIANCE

LOCATION: Billings, MT (or other locations)

JOB TYPE: Full-Time Permanent

The Director of Clinical Compliance is responsible for providing leadership and oversight of regulatory compliance, quality assurance, and clinical integrity across all hospice operations. This position ensures full adherence to applicable federal and state regulations, Conditions of Participation (CoPs), accreditation standards, and internal organizational policies and procedures. Serving as both a strategic and operational leader, the Director establishes and maintains systems to ensure continuous regulatory readiness, mitigate organizational risk, and promote the delivery of safe, high-quality, and compassionate care to patients and families.

Key Responsibilities

Regulatory Compliance and Oversight

• Maintain comprehensive knowledge of CMS Conditions of Participation (CoPs), state regulations, and accreditation requirements (CHAP, ACHC, or Joint Commission).
• Conduct ongoing internal compliance audits and clinical documentation reviews to ensure regulatory and organizational alignment.
• Coordinate and lead preparation for external surveys, audits, and accreditation reviews.
• Identify areas of noncompliance, implement corrective action plans, and monitor outcomes to ensure sustainable improvement.
• Collaborate with internal and external stakeholders to ensure consistency of policies, procedures, and clinical practices across all operating sites.

Quality Assurance and Performance Improvement (QAPI)

• Direct the QAPI program to ensure measurable improvement in patient outcomes, operational performance, and satisfaction metrics.
• Analyze quality data, including HIS/HOPE and CAHPS, to identify trends and develop targeted performance improvement initiatives.
• Lead monthly quality meetings and ensure interdisciplinary participation.
• Ensure timely submission, documentation, and reporting of all QAPI data as required by federal and state regulations.

Education and Training

• Develop, implement, and deliver education and training programs related to compliance, documentation, CoPs, HIPAA, and ethical practices.
• Oversee onboarding and continuing education for clinical leaders.
• Support survey preparedness and ongoing staff competency validation.
• Mentor regional and branch clinical leaders to promote a culture of regulatory compliance, clinical excellence, and accountability.

Risk Management

• Proactively identify, investigate, and resolve potential compliance concerns, adverse events, and grievances.
• Partner with Human Resources and Executive Leadership to ensure consistent and compliant resolutions.
• Maintain confidential mechanisms for reporting compliance issues and ensure timely and appropriate follow-up.
• Prepare and present executive reports summarizing compliance trends, risks, and corrective actions.

Clinical Leadership and Collaboration

• Partner with regional and branch clinical leadership to ensure consistent clinical practices and documentation standards.
• Conduct focused chart reviews and clinical assessments to verify adherence to care and regulatory standards.
• Serve as a compliance resource for emerging markets and new operational initiatives.
• Participate in strategic leadership discussions to align compliance and quality initiatives with organizational goals.

Qualifications

Education:

• Bachelor of Science in Nursing (BSN) required.
• Master’s degree in Nursing, Healthcare Administration, or related field preferred.

Licensure:

• Active, unrestricted Registered Nurse (RN) license in any U.S. state.
• Multi-state eligibility preferred.

Experience:

• Minimum of three (3) years of clinical experience in hospice or home health.
• Minimum of one (1) year of leadership experience in compliance, quality management, or regulatory oversight within hospice operations.

Knowledge and Skills:

• Expert understanding of hospice Conditions of Participation, Medicare regulations, and state-specific requirements.
• Proficiency in accreditation standards and survey readiness processes.
• Strong analytical skills with demonstrated ability to interpret data and implement process improvements.
• Exceptional communication, leadership, and organizational skills.
• Proficiency in EMR systems and Microsoft Office applications.
• Ability to manage multiple priorities across geographically dispersed teams.

Core Competencies

• Regulatory and Clinical Expertise
• Quality Improvement and Data Analysis
• Leadership and Mentorship
• Ethical and Sound Judgment
• Strategic Compliance Planning
• Risk Mitigation and Corrective Action Execution

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