Compliance , Quality & Education Mgr - Hospice RN - Carmel, IN

Compliance, Quality, Education Manager · Position Summary: · This is a dual role that will split into the Clinical Compliance Manager and the Quality Education Manger as growth occurs in the branch. The Compliance portion of this position is responsible for executing clinical com ...

Job description

Compliance, Quality, Education Manager

Position Summary:

This is a dual role that will split into the Clinical Compliance Manager and the Quality Education Manger 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.

The Clinical Compliance portion translates audit findings into practical education and coaching for clinical staff, ensuring sustained compliance with CMS Conditions of Participation, accrediting body standards, and applicable state and federal regulations. This position functions as both a quality strategist and educator, ensuring regulatory compliance, financial stewardship, staff competency, and consistent hospice practice across all disciplines. The Quality & Education portion partners closely with Administrators, branch leadership, and field staff to drive measurable improvement in quality outcomes, staff engagement, and fiscal responsibility.

Required Experience:

• 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.

Preferred Experience:

• 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.

Compliance Responsibility:

• 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.

Quality and Education Responsibility:

• 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, accountability, and measurable outcomes.
• Monitor and lead performance improvement for:
  • Hospice Outcomes and Patient Evaluation (HOPE) scores
  • Hospice Care Index (HCI)
  • CAHPS Hospice Survey results
• Create and deliver targeted education and remediation plans for metrics not meeting company-defined expectations.
• Audit clinical records to identify education gaps for both leadership and field staff; develop and deploy corrective education plans.
• Evaluate all live discharges and patients not taken under care; provide education to staff and leadership on decision rationale, documentation standards, and regulatory risk.
• Develop, maintain, and deliver creative, engaging education solutions for all hospice disciplines, including:
  • Nursing
  • Social Work
  • Chaplaincy
  • Certified Nursing Assistants
  • Branch and Executive Leadership
• Assist Orientation Lead as needed with company policies, procedures, and the principles of effective hospice case management.
• Mentor field staff directly when needed to reinforce education, support performance improvement, and model best practices.
• Ensure education plans are sustained through re-education, auditing, and reinforcement over time.
• Monitor DME, pharmacy, and supply utilization; identify non-improving trends.
• Develop and oversee Plans of Correction for budget variances that do not improve.
• Review, evaluate, and approve or deny all over-par or over-budget DME, pharmacy, and supply requests.
• Partner with leadership to balance quality outcomes with responsible financial stewardship.
• Mentor and educate Administrators in leadership development, organization, and operational excellence.
• Monitor EMR usage patterns and provide targeted education where gaps are identified.
• Develop Employee Engagement Plans with a strong focus on nursing staff retention.
• Monitor turnover rates and create Performance Improvement Plans when engagement or retention metrics fall below company expectations.
• Serve as a subject-matter expert in hospice customer service, patient experience, and relationship management across complex care settings.
• Educate and mentor hospice staff on delivering exceptional customer service while caring for patients residing in Independent Living (IL)/ Enhanced Living (EL) and Assisted Living (AL)/ Memory Care (MC) communities owned or operated by the organization.
• Train field staff and branch leadership on:
  • Professional communication with IL/EL and AL/MC staff
  • Role clarity between hospice and residential care services
  • Managing expectations, boundaries, and collaboration to reduce conflict and complaints
• Support education related to:
  • Transitions of care between IL/EL and AL/MC and hospice
  • Managing family expectations in congregate living environments
  • Navigating shared ownership dynamics while maintaining hospice compliance and clinical integrity
• Partner with IL/EL and AL/MC leadership as needed to:
  • Address recurring concerns or complaints involving hospice services
  • Improve coordination, communication, and mutual understanding of roles
• Incorporate customer experience principles into:
  • Education plans
  • Performance improvement initiatives
  • Staff mentoring and remediation efforts

Skills for Success:

• Clinical documentation review and regulatory interpretation
• Audit execution and issue identification
• Education and field coaching
• Professional communication and collaboration
• Organization, time management, and follow-through
• Ability to work independently in a remote environment

General Working Conditions:

This position entails sitting for long periods of time. While performing the duties of this job, the employee is required to communicate effectively with others, sit, stand, walk and use hands to handle keyboard, telephone, paper, files, and other equipment and objects. The employee is occasionally required to reach with hands and arms. This position requires the ability to review detailed documents and read computer screens. The employee will occasionally lift and/or move up to 25 pounds. The work environment requires appropriate interaction with others. The noise level in the work environment is moderate. Ability to wear Personal Protective Equipment (PPE).

• Primarily remote with travel to assigned hospice locations as needed.
• May require availability during surveys, audits, or regulatory events.

This classification description is intended to indicate the general kinds of tasks and levels of work difficulty that are required of positions given this title and should not be construed as declaring what the specific duties and responsibilities of any particular position shall be. It is not intended to limit or in any way modify the right of any supervisor to assign, direct and control the work of the employees under her/his supervision. The use of a particular expression or illustration describing duties shall not exclude other duties not mentioned that are of a similar kind or level of difficulty.

Equal Opportunity Employer

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