Compliance , Quality & Education Mgr - Hospice RN

Position Summary

This is a dual role that will split into the Clinical Compliance Manager and the Quality Education Manager as growth occurs in the branch. The Compliance portion of this position is responsible for executing clinical compliance audits, monitoring regulatory adherence, and supporting survey readiness across the assigned hospice location. This role identifies compliance risks through medical record review, operational audits, regulatory monitoring, and branch mock audits and works collaboratively with clinical leadership to implement corrective actions.

The Quality & Education portion of this position is the authority for hospice quality, education, and performance improvement. This role is responsible for the full QAPI lifecycle from data collection and analysis through facilitation of QAPI meetings, development of corrective action plans, education rollout, and sustained performance improvement monitoring.

• Registered Nurse (RN) license, active and in good standing.
• Minimum of 6-8 years of hospice experience.
• Working knowledge of CMS Conditions of Participation and accreditation standards.
• Experience with medical record review, audits, or quality/compliance activities.
• Strong clinical documentation skills and attention to detail.

• Experience in hospice compliance, quality, or survey preparation roles.
• Multi-state hospice experience (Michigan, Ohio, Indiana preferred).
• Prior participation in surveys, audits, ADRs, or corrective action processes.
• Compliance or quality certification (e.g., CHC, CHPC, CHPN) preferred but not required.

• Conduct routine, focused, and for‑cause clinical compliance audits in accordance with established audit tools and methodology.
• Perform detailed medical record reviews to assess compliance with CMS Conditions of Participation, accreditation standards, and internal policies.
• Identify documentation gaps, regulatory risks, and patterns of non‑compliance across clinical disciplines.
• Maintain accurate, timely audit documentation and tracking to support trend analysis and reporting.
• Analyze audit findings to identify systemic issues, repeat deficiencies, and areas of elevated compliance risk.
• Collaborate with clinical leadership to develop corrective action plans that are practical, measurable, and sustainable.
• Monitor corrective actions through completion and validate effectiveness through follow‑up audits.
• Escalate high‑risk findings and unresolved issues to the Regional Director of Compliance and Denial Management.
• Translate audit findings into targeted, role‑specific education for clinical staff and leaders.
• Provide real‑time coaching and mentoring to clinical staff related to documentation standards and regulatory expectations.
• Participate in the development and delivery of compliance education related to audit outcomes, regulatory changes, and survey readiness.
• Reinforce best practices for defensible, audit‑ready clinical documentation.
• Support ongoing survey readiness activities across assigned locations.
• Participate in mock surveys, tracers, and focused reviews as directed.
• Serve as a compliance resource during surveys, audits, ADRs, and regulatory inquiries.
• Assist in preparation of documentation and responses related to audits, surveys, or investigations.
• Work collaboratively with Quality/ Education, Clinical Operations, and Leadership teams to support compliance initiatives.
• Communicate audit findings and expectations clearly, professionally, and in a non‑punitive manner.
• Provide routine updates and reports to the Regional Director of Compliance and Denial Management regarding audit results, trends, and risk areas.

• Own and lead the hospice QAPI program, including:
  • Data gathering, analysis, trending, and interpretation
  • Development of agendas, facilitation of QAPI meetings, and documentation of outcomes
  • Translation of findings into actionable Performance Improvement Plans
• Develop, implement, and monitor Quality Improvement Plans that drive sustained performance improvement across the assigned region.
• Serve as Project Manager for all quality‑related initiatives, ensuring timelines,…