VP Quality and Compliance

Job Description

Due to promotion within our team, we are hiring to fill a role with corporate leadership responsibilities in quality, education and compliance.

This is a full-time, salaried, exempt position

Schedule: Monday-Friday 8am-5pm

This position directs the agency quality improvement and corporate compliance programs, including safety and infection control, to ensure full compliance with regulatory requirements and accepted standards of practice and excellence in patient outcomes. Scope of responsibility encompasses all settings of the organization. This position also directs the education program, which promotes employee professional growth, and the quality of services provided. A member of senior leadership, this position serves as a liaison between the clinical staff and Chief Clinical Officer.

What are the essential duties?

Develops and leads implementation of an annual comprehensive quality plan including annual plan evaluation, to support continuous performance improvement; plan is data driven and organization wide. Reports plan and results to the senior leadership team, Quality Committee, and Board of Directors.

Responsible for collection, aggregation, analysis and synthesis of data relating to quality indicators in order to make recommendations for improvement in service, processes in care or operations.

Responsible for tracking adverse events (organization accidents, incidents, complaints, etc.), analyzing data and determining trends and causes. Develops corrective action plan with input of appropriate staff and presents to senior leadership team. Serves as facilitator for Quality Committee.

Coordinates and facilitates implementation and evaluation of performance improvement teams. Ensures development of formal projects based on identifiable priorities, i.e., high use, high volume and problem prone.

Oversees, coordinates and monitors the implementation of the Compliance Program and day-to-day compliance activities, with regular reports to senior leadership and Board of Directors.

Assists with departmental specific audits (e.g., clinical, human resources, billing, etc.) as needed or requested, to ensure compliance with applicable regulations.

Develops, coordinates, and participates in the compliance education and training program.

Ensures independent contractors and agents who furnish physician, nursing, or other services to patients are aware of the requirements of the compliance program.

Independently investigates and acts on matters related to compliance, including designing and coordinating internal investigations and corrective actions.

Monitors the reporting mechanism that enables employees and contractors to report any non- compliance without fear of retaliation and ensures adequate publicity for the reporting mechanism.

Responsible for responding to requests for medical records (e.g., ADRs, CERT requests, DMA Program Integrity requests, PGBA Medical Review sample/probe edits, subpoenas, etc.).

Serves as Corporate Compliance Officer.

Leads agency in triennial reaccreditation process and other clinical regulatory surveys, as they may occur.

Participates in policy and procedure development and regular review, revision and approval of clinical policies and procedures.

What are the requirements for this role?

Graduate of an accredited college or university with a bachelor's degree in nursing, social work, counseling, quality, healthcare administration, or other hospice-related discipline.

A minimum of three years of relevant experience, including at least one year in a leadership, supervisory, or quality/compliance role.

Certification in a related discipline or quality specialty is required (examples include CPHQ—Certified Professional in Healthcare Quality, CHC—Certified in Healthcare Compliance, or relevant certification in nursing, social work, or counseling).

Certification in Hospice & Palliative Care is desirable but not required.

Must maintain valid personal automobile insurance at limits required by the agency.

Valid NC driver’s license, reliable independent transportation, and current automobile liability.

Are you a good fit for this role? Here are some things we find very valuable..

Excellent verbal and written communication skills

Excellent interpersonal and customer service skills

Proficient in Microsoft Office Suite, Adobe or related software

Data analysis skills

Policy development skills

Change management skills

Ability to build cohesiveness amongst a team

Ability to prepare and present information to leadership/organization

Ability to design an effectively implement training programs

Passionate about teaching/educating

Understanding of hospice or Medicare regulations

Risk reduction management

Ability to respond to complaints/grievances in an appropriate and effective manner

Here is what our employees have to say about working here:

This is the best organization I have ever worked for. What makes it stand out the most is the culture of trust and understanding created by senior leadership, which filters down to every level of the organization and provides a safe environment for everyone to do and be their best.

We are the best because we are encouraged to be the best.

Everyone who works here is focused on the mission of providing the best end of life care possible. This includes not just the clinical staff but also the support staff who are made to feel a part of the team.

This organization is one of a kind. From the top to the bottom, there is respect, integrity, and kindness. Our leaders lead by example.

Employees are put first along with a balance for what will ensure a healthy organization.

Words from our most recent VP, Quality and Compliance:

In this role, there is autonomy and opportunity for professional growth.

I really love knowing that I am a protector/gatekeeper of the organization. I do this by advocating for our employees, patients and families.

This is a behind the scenes role, but it has a very high impact throughout the organization.

I am able to influence the standard of care.

Full-time