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Alive Hospice

Quality and Regulatory Compliance Manager

Alive Hospice


Job Summary

Are you a Quality/Regulatory Compliance professional who desires to work in a capacity in which your efforts directly impact clinicians, patients and their loved ones?

If you are eager to use your talents and skill set in a way that truly makes a difference in the Middle TN healthcare market, we can’t wait to talk with you!


The Quality and Regulatory Manager provides direction and oversight of the organizations Quality Improvement and Performance Improvement plan (QAPI) and Regulatory Standards for Alive Hospice.  The Quality and Regulatory Manager is responsible for collaboration with all agency departments to drive the organizations compliance with regulatory and accreditation standards and facilitates process improvement through appropriate data collection, analysis, sharing and application; along with leading process improvement efforts to ensure compliance with agency, local, state and national quality initiatives.

For purposes of clarification, Regulatory Compliance is defined as all health care regulatory compliance including OIG, CMS, TJC, and HIPAA and other regulations that directly or indirectly impact the operations of Alive Hospice.

Job Responsibilities


  • Collaborate with the Director of Quality and Compliance to achieve department and organization goals and outcomes
  • 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
  • Regularly review the QAPI program and recommends appropriate revisions and modifications to the Director of Quality and Compliance
  • 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 monitoring and reporting
  • Present periodic and annual reports on the QAPI Program
  • Develop, coordinate, and/or oversee internal and external audit procedures for the purpose of monitoring and detecting performance improvement opportunities
  • Recommend solutions, and follow up to ensure that the recommendations have been implemented and are effective
  • Service recovery monitoring and follow up
  • Collaborate with Healthcarefirst for collection and reporting of family satisfaction surveys
  • 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



  • Monitor state, federal and The Joint Commission (TJC) Regulatory Compliance to help the organization prevent and/or detect violation of law, regulations, policies, or the Code of Conduct.
  • Coordinate resources to ensure the ongoing survey readiness and adherence to state, federal an accreditation standard
  • Develop education programs for all employees, agents, affiliated providers, or others working with the organization
  • Oversee follow-up and, as applicable, resolution to survey deficiencies and self-assessments
  • Facilitate plan of correction activities and follow up.
  • Develop productive and collaborative working relationships with all levels of management.
  • Work with Department Leadership to provide adequate information to employees of to ensure that they have the requisite information and knowledge of regulatory issues and requirements to carry out their responsibilities in a lawful and ethical manner
  • Ensure and understand the company’s commitment to comply with all laws, regulations, company policies, and ethical requirements applicable to the conduct of the business
  •  Assess the need for additional training and education and develop appropriate regulatory compliance tools and resources.
  • Carry out all duties and responsibilities as assigned by the board appointed Quality and Compliance Committee and/or under the Corporate Integrity Program.
  • Perform other duties as assigned


Direct oversight of the Infection Prevention program.  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.



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


An active RN license is required for this position. If required to drive to carry out the duties of this position: current driver’s license and automobile insurance as required by Tennessee State Law

Additional Information


Health, dental and vision coverage available. The opportunity to contribute to a 403b plan, and paid time off is also available.

How to Apply

View job posting and submit applications at


  • Date Posted: February 22, 2021
  • Type: Full-Time
  • Job Function: Analytics / Evaluation
  • Service Area: Health (Physical, Mental)
  • Start Date: 04/19/2021
  • Working Hours: M-F 8:00 am - 5:00 pm