Director of Clinical Compliance

*Essential Duties and Responsibilities*

• Oversee the organization’s clinical compliance program and promote adherence to Medicare Hospice Conditions of Participation, state regulations, accreditation requirements, and internal policies.
• Maintain continuous readiness for Medicare, state, accreditation, and other regulatory surveys.
• Lead survey preparation activities, including mock surveys, record reviews, staff interviews, home-visit observations, and follow-up on identified deficiencies.
• Serve as a primary clinical compliance resource before, during, and after regulatory surveys.
• Review survey findings and coordinate plans of correction, implementation, monitoring, and documentation of sustained compliance.
• Conduct routine and targeted audits of clinical records, plans of care, certifications and recertifications, eligibility documentation, levels of care, interdisciplinary group processes, medication management, and other hospice requirements.
• Identify patterns, compliance risks, and opportunities to improve clinical quality and operational performance.
• Partner with the Administrator, Director of Nursing, Medical Director, Quality team, and other leaders to address clinical and regulatory concerns.
• Participate in or provide oversight for the Quality Assessment and Performance Improvement (QAPI) program.
• Monitor quality indicators, adverse events, complaints, grievances, infections, hospitalizations, revocations, live discharges, and other relevant clinical outcomes.
• Lead investigations involving potential clinical noncompliance, patient-care concerns, or failures to follow organizational policies.
• Develop, review, and update clinical policies, procedures, audit tools, and compliance education.
• Educate clinical leaders and staff regarding Medicare CoPs, documentation standards, survey expectations, and regulatory changes.
• Validate that corrective actions are implemented and effective through follow-up audits and performance monitoring.
• Prepare clear compliance reports and recommendations for executive leadership and governing-body review.
• Promote a culture of accountability, integrity, patient safety, and continuous improvement.
• Perform other related duties as assigned.

*Required Qualifications*

• Active, unrestricted Registered Nurse license in the state of Oregon.
• Minimum of three years of direct clinical hospice experience.
• Thorough working knowledge of Medicare Hospice Conditions of Participation and hospice regulatory requirements.
• Direct experience preparing for and participating in Medicare, state, or accreditation surveys.
• Previous clinical leadership experience in hospice, such as Director of Nursing, Administrator, Executive Director, Vice President of Clinical Services, Regional Clinical Director, or a comparable senior leadership position.
• Demonstrated experience with clinical auditing, plans of correction, QAPI, policy development, and regulatory compliance.
• Strong knowledge of hospice clinical documentation, eligibility, certification, interdisciplinary care planning, and patient-care standards.
• Ability to interpret regulations and translate them into practical clinical and operational processes.
• Strong leadership, communication, organization, investigation, and problem-solving skills.
• Ability to manage sensitive and confidential information with professionalism and discretion.
• Proficiency with electronic medical record systems and standard business software.

*Preferred Qualifications*

• Bachelor of Science in Nursing; master’s degree in nursing, healthcare administration, or a related field is preferred.
• Five or more years of hospice experience.
• Multi-site, regional, or enterprise-level hospice compliance experience.
• Experience with CMS survey protocols and accreditation organizations such as CHAP, ACHC, or The Joint Commission.
• Certification in healthcare compliance, quality, or hospice and palliative nursing is preferred.

*Core Competencies*

• Regulatory and clinical expertise
• Ethical judgment and professional integrity
• Executive-level leadership
• Survey and audit readiness
• Quality improvement and risk identification
• Clear written and verbal communication
• Coaching and staff development
• Collaboration across clinical and operational teams
• Analytical thinking and attention to detail
• Accountability and follow-through

*Physical and Travel Requirements*

This position may require prolonged periods of sitting, computer use, reviewing clinical records, and participating in meetings.

*Why Join Gracious Care Hospice?*

At Gracious Care Hospice, we are committed to providing compassionate, dignified, and clinically excellent care to patients and families. The Director of Clinical Compliance will play an essential role in protecting that commitment by strengthening our clinical practices, supporting our teams, and ensuring that quality and compliance remain central to everything we do.

*Equal Employment Opportunity*

Gracious Care Hospice is an equal opportunity employer. Employment decisions are made without regard to race, color, religion, sex, pregnancy, national origin, age, disability, genetic information, veteran status, or any other status protected by applicable law.

Pay: $120,000.00 - $145,000.00 per year

Benefits

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Referral program
• Vision insurance

Work Location: In person