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Alive Hospice

Director of Quality and Compliance

Alive Hospice


Job Summary

The Director of Quality and Compliance provides direction and oversight of performance improvement through data and quality and compliance measurements to provide direction and oversight of the QAPI with leading process improvement efforts to ensure compliance with agency, local, state and national quality initiatives. 

The Director of Quality and Compliance is also responsible Identifying and assessing areas of compliance risk for the organization; communicating the importance of the QAPI program to executive management and the Board of Trustees;  preparing and distributing the written Code of Conduct setting forth the ethical principles and policies, which are the basis of the Compliance Program; developing and implementing education programs addressing compliance and the Code of Conduct; implementing a retaliationfree internal reporting process, including an anonymous telephone reporting system; and collaborating with executive management to effectively incorporate the Compliance Program within system operations and programs and to carry out the responsibilities of the position.

Job Responsibilities

*See posting at for complete list of responsibilities.

  • Quality
    • Collaborate with the VP of Information Technology and Security for optimization of Agency information systems to support and improve processes
    • Facilitation of Root Cause Analysis (RCA), Failure Mode Effects Analysis (FMEA), and Performance Improvement efforts
    • Data gathering to identify opportunities for performance improvement
    • Collaboration with all stake holders to ensure reporting needs are identified and met
    • Analytic support for departments across the organization
    • CMS quality reporting
    • Incident reporting and service recoveries
    • Collaborate with Deyta for collection and reporting of family satisfaction surveys
    • Contract management
    • Electronic Medical Record (EMR) enhancement support
    • Collaborate with VP of Information Technology and Security to design and/or refine data tools and systems to streamline agency processes
  • Compliance
  • Monitoring the Compliance Program to help the organization prevent and/or detect violation of law, regulations, policies, or the Code of Conduct.
  • Regularly reviewing the Compliance Program and recommending appropriate revisions and modifications, including advising Executive Management and the Board of Trustees of potential compliance risk areas.
  • Coordinating resources to ensure the ongoing effectiveness of the Compliance Program.
  • Implementing and operating retaliationfree reporting channels, including an anonymous telephone reporting system available to all employees, volunteers, and affiliated providers.
  • Developing education programs for all employees, agents, affiliated providers, or others working with the organization.
  • Ensuring that the internal controls are capable of preventing and detecting significant instances or patterns of illegal, unethical, or improper conduct by employees, agents, affiliated providers, or others working with the organization.
  • Ensuring that the system has effective mechanisms to reasonably determine that persons either promoted to or hired in management and certain other sensitive and/or responsible positions (to be designated) do not have a propensity to violate federal or state laws and regulations or engage in improper or unethical conduct in their designated areas of responsibility.


  • Manages and supervises employees involved with quality, compliance, analytics, medical records,
  • Responsible for the overall direction, coordination, and evaluation of these teams.
  • Carries out supervisory responsibilities in accordance with the organization’s policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.


To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.


Valid RN license required, Bachelor’s degree, Master’s preferred; CPHQ (Certified Professional in Healthcare Quality) preferred; 3-5 years Clinical Informatics background; demonstrated professional experience working with clinical records, documentation, billing and auditing. 

Additional Information


Medical, dental and vision insurance available, as well as opportunity to contirubte to 403(b) plan. Long and short-term disability available.  Generous paid time-off plan.

How to Apply

Review complete job description and apply at



  • Date Posted: February 17, 2021
  • Type: Full-Time
  • Job Function: Analytics / Evaluation
  • Service Area: Health (Physical, Mental)
  • Working Hours: M-F 8:00 am - 5:00 pm