Compliance Strategy and Regulatory Oversight
• Partner with the VP of Compliance and Quality to develop and execute the organization’s hospice compliance strategy.
• Monitor federal and state regulatory changes across all operating markets and assess organizational impact.
• Ensure organizational compliance with Medicare Conditions of Participation (CoPs), state licensing requirements, and accreditation standards.
• Serve as a subject matter resource on hospice regulatory requirements for operational and clinical leadership.
• Provide direct oversight of the Clinical Compliance and Audit sub-team, managing both clinical and technical audit functions.
• Design and maintain the internal audit plan, including scope, frequency, and focus areas informed by regulatory risk and external audit trends (TPE, CERT, UPIC).
• Review and analyze audit findings, identifying patterns and systemic issues that require corrective action or clinical education.
• Collaborate with the Clinical Nurse Educator team to translate audit findings into targeted education initiatives for clinical staff.
Corrective Action Plan (CAP) Management
• Own the corrective action lifecycle from root cause analysis through resolution and re-monitoring, in strategic partnership with the VP of Compliance and Quality.
• Develop, track, and close corrective action plans resulting from internal audits, external audits, survey findings, and incident investigations.
• Monitor CAP effectiveness and report on closure timelines and outcomes.
• Own the policy management lifecycle including development, scheduled review cycles, regulatory alignment, and approval workflows.
• Ensure policies remain current with CMS requirements, state regulations, and accreditation standards across all operating markets.
• Coordinate with the Associate Director of Regulatory Compliance and Quality on policy administrative infrastructure (version control, distribution, acknowledgment tracking).
• Conduct internal compliance investigations in partnership with the VP of Compliance and Quality, including documentation of findings, root cause identification, and recommended corrective actions.
• Share investigative responsibilities with the VP based on complexity, scope, and regulatory implications.
• Escalate matters requiring external or legal investigation to the VP of Compliance and Quality.
• Maintain investigation documentation in accordance with organizational and regulatory requirements.
Incident, Complaint, and Grievance Oversight
• Provide operational oversight of the incident, complaint, and grievance process, with administrative management performed by the Associate Director of Regulatory Compliance and Quality.
• Review trends in incident and grievance data and recommend process improvements.
• Report on incident and grievance trends to the VP of Compliance and Quality for executive-level reporting.
• Coordinate the organization’s response to external audits including TPE, CERT, and UPIC reviews.
• Prepare documentation and manage timelines for audit responses and appeals.
• Track external audit outcomes and incorporate lessons learned into the internal audit plan and education priorities.