The Director of Compliance is responsible for the overall management of the Quality Assurance team and the education related to compliance needs of the hospice. The director will oversee the accuracy of documentation in the medical record and assure the hospice and palliative care services comply with regulatory guidelines. The director manages the continuous quality improvement process and all education provided by the staff development coordinator. The director works in conjunction with the Director of Education to ensure the hospice agency is in compliance with regulations and that the educational needs of the hospice staff are met.
Reports to: Chief Executive Officer
Supervises: Medical Records Department
Others: Interacts with IDT and other administrative staff
Duties and Responsibilities
- Stewards the philosophy/mission of PH Healthcare, which focuses on the overriding values of human dignity and respectful response to the needs of persons with life threatening/terminal and/or chronic illnesses.
- Supervises the compliance department.
- Assures medical records and other agency forms are accurate, meet regulatory requirements, and documentation procedures are followed by all staff.
- Assures confidentiality of medical records and compliance with HIPAA and other regulatory bodies.
- Assures the compliance of the hospice agency in all areas.
- Coordinates the quarterly quality assurance meeting and facilitates staff involvement in quality assurance auditing activities.
- Oversees the developmental needs of the hospice and coordinates with the Director of Education on developing educational programs and in-service education.
Must possess, as a minimum, a Nursing Degree from an accredited college or university and be licensed as a Registered Nurse in the state of South Carolina. Must have a minimum of one year hospice or long term care experience. Previous experience as a staff educator and experience in auditing medical records in hospital or long-term care facility is preferred.
Knowledge, Skills, and Abilities
- Must be able to read, write, speak, and understand the English language.
- Must be available to hospice staff, be responsive to inquiries and act appropriately to attempt to resolve problems.
- Must possess the ability to make independent decisions when circumstances warrant such action.
- Must possess the ability to deal tactfully with personnel, patients, family members, visitors, government agencies/personnel, and the general public.
- Must be knowledgeable of hospice nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to hospice.
- Must possess leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel.
- Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality care.
- Must have patience, tact, as well as the willingness to handle difficult residents.
- Must be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices.
- Must not pose a direct threat to the health or safety of other individuals in the workplace.
- Must have knowledge of HIPAA compliance and regulations.
- Must have effective computer skills.
- Requires travel within the agency’s service area in personal automobile, therefore, must have a current driver’s license, auto insurance, and have the ability to operate an automobile.
- Works in office area(s), community and long term care facilities.
- Moves intermittently during working hours.
- Is subject to frequent interruptions.
- Is involved with patients, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances.
- Is subject to hostile and emotionally upset patients, family members, personnel, and visitors.
- Communicates with the medical staff, nursing personnel, and other department supervisors.
- Works beyond normal working hours when necessary.
- Is subject to call-back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.)
- Is involved in community/civic health matters/projects as appropriate.
- Attends and participates in continuing educational programs.
- Is subject to injury from falls, burns from equipment, odors, etc., throughout the workday, as well as to reactions from dust, disinfectants, tobacco smoke, and other air contaminants.
- Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses.
- May be subject to the handling of and exposure to hazardous chemicals.
- Must be able to push, pull, move, and/or lift a minimum of 25 pounds to a minimum height of 5 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 50 feet.
* Please note every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.