Director of Compliance (Remote)

Position Summary

The Director of Compliance provides strategic leadership for the organization's hospice compliance program. This role focuses on regulatory oversight, risk management, audit program governance, policy governance, and corrective action management. The Director serves as the operational leader of the Clinical Compliance and Audit sub-team, translating organizational compliance strategy into day-to-day execution while partnering with the VP of Compliance and Quality on enterprise-level initiatives.

Essential Functions

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.

Audit Program Governance

• 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.

Policy Governance

• 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).

Investigations

• 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.

External Audit Response

• 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.

Qualifications

Required

• Bachelor's degree in Nursing, Healthcare Administration, or related field.

• Active RN license required.

• Clinical background in hospice or home health required.

• Minimum 5 years of experience in healthcare compliance, quality, or regulatory affairs, with at least 2 years in a leadership role.

• Demonstrated knowledge of Medicare hospice Conditions of Participation, state licensing requirements, and CMS audit processes (TPE, CERT, UPIC).

• Experience developing and managing corrective action plans and policy governance programs.

• Strong analytical skills with the ability to identify patterns in audit data and translate findings into actionable recommendations.

Preferred

• Master's degree in Healthcare Administration, Nursing, or related field.

• Certification in Healthcare Compliance (CHC) or equivalent.

• Experience with MatrixCare or comparable EMR systems.

• Multi-state hospice compliance experience.

• Experience conducting internal investigations.