Director of Quality & Compliance

Northern Illinois Hospice is a trusted and growing agency. Founded in 1979, we were the first hospice agency in our region and one of the first 50 in the nation. We are looking for exceptional people to join our exceptional team. People who want to make a difference in the community and in the lives of others.

We are seeking a dedicated Director of Quality & Compliance with the highest standards of excellence, who seeks the opportunity to work for an employer that’s the leader in patient-focused, team-based hospice care and committed to creating a culture of excellence.

The Director of Quality and Compliance is a key leadership position responsible for overseeing the organization’s quality, safety, and continuous improvement, and regulatory compliance. This position works under the direction of the Chief Executive Officer with a dotted line to the Board of Directors, and has a collaborative relationship with leadership, cultivating a unified and cohesive strategy for organizational excellence.

Areas of oversight, monitoring, and reporting include clinical quality, safety, and continuous improvement; infection control; emergency management; regulatory, Joint Commission, and policy/procedure compliance; quality/compliance education; and medical records and data management.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Oversees the Quality Program and makes periodic and annual reports and recommendations to leadership.
• Leads Quality Committees, including the Board Quality Assessment (QA) Committee and the Quality Assurance and Performance Improvement (QAPI) committee.
• Maintains awareness of new quality trends, practice tools, and techniques through active participation in State and National organizations and work groups and makes useful and applicable organizational change as appropriate.
• Facilitates Root Cause Analysis (RCA), Failure Mode Effects Analysis (FMEA), and Performance Improvement efforts.
• Oversees quality and compliance education programs, identifies training needs, tracks participation, trains the trainers, and facilitates training as appropriate to ensure regulatory and Joint Commission compliance, best practice in hospice and palliative care quality and safety, infection control, and emergency preparedness.
• Ensures organizational compliance with all state, federal, and Medicare Conditions of Participation (CoPs) regulations and Joint Commission standards for hospice care and palliative care, including the quality data and performance collection, analysis, and reporting by deadline.
• Serves as the organization’s liaison to The Joint Commission, acting as its subject matter expert, and leads team members to ensure survey readiness, Intracycle Monitoring (ICM), and post-survey and plan of correction compliance.
• Oversees the Compliance Program and makes periodic and annual reports and recommendations to leadership on the organization’s internal controls, adherence to regulations, handling of performance issues related to compliance, and other risk-mitigating activities.
• Oversees the organization’s infection control program, including infection rates and trends, training, and reporting, and implements prevention strategies.
• Collects and analyzes key compliance metrics, and utilizes data to identify trends, monitor outcomes, and support decision-making.
• Monitors the organization’s reporting system to ensure timely incident and complaint reporting and analysis, and implements a blame-free, retaliation-free culture of reporting.
• Oversees the investigation and resolution of compliance issues, reporting findings as appropriate to leadership and external agencies.
• Demonstrates knowledge/respect of patient rights and responsibilities; privacy and confidentiality; and safety, including reporting of patient abuse, mistreatment, exploitation, and/or neglect. Also provides interdisciplinary team guidance and oversight on reports of suspected cases of patient abuse, mistreatment, exploitation, and/or neglect.
• Mitigates organizational risk, conducting and/or overseeing internal audits; providing guidance on regulatory or accreditation standard changes that necessitate policy, clinical practice, form, contract, etc. changes; and seeking outside compliance consultants and/or legal counsel when necessary.
• Provides oversight and periodic audits of medical records management to ensure timely documentation completion and accuracy, appropriate access rights, and appropriate storage and handling of record requests in compliance with legal and regulatory requirements.
• Informs Chief Executive Officer and Board in a timely manner of matters affecting quality, compliance, and organizational well-being. Communicates as well as seeks guidance and direction utilizing the proper chain of command.
• Oversees and collaborates with the Facilities Manager the organization’s emergency preparedness to ensure compliance with federal and state regulations and Joint Commission standards, including the satisfactory completion of ongoing and annual requirements.
• Collaborates with the Director of Human Resources, ensures fair, equitable, and consistent practices for investigating and addressing incidents of staff noncompliance and/or the failure to prevent, detect, or report any noncompliance.

Duties and Responsibilities Performed in Collaboration with the Director of Clinical Services

• Leads and manages quality improvement initiatives to ensure the organization meets and exceeds state and federal regulation and Joint Commission standards.
• Promotes a culture of accountability, integrity, excellence, and continuous improvement throughout the organization. Establishes and monitors goals to drive excellence in care delivery and organizational operations.
• Conducts data analysis, recommends, and oversees performance improvement plans to address gaps in care, compliance, and patient outcomes.
• Enforces HIPAA privacy regulations and conducts risk assessments and staff training.
• Mentors new hires and ensures education aligns with quality and compliance initiatives.
• Serves as the organization’s Safety Officer and collaborates with the Incident Command team during emergencies.
• Supports data security and regulatory compliance, integrity, and accuracy, and assists with identifying and improving data collection and efficiency.

Northern Illinois Hospice supports our employees’ wellbeing and regularly benchmarks with other companies in our industry to offer an extensive Total Reward package for this position. The expected base salary range for this role is $104,617 - $156,925. However, final base pay will be carefully determined based on several factors, including education, experience, knowledge, skills, and abilities, as well as internal equity and alignment with market data. Additionally, this role may be eligible for other forms of compensation and benefits.

BENEFITS:

• Comprehensive Benefits Package Access a well-rounded benefits package designed to support your well-being.
• Choice of Medical Plans: Choose from two medical plans tailored to fit your unique healthcare needs.
• Health & Wellness Accounts: Manage expenses with a Health Savings Account (HSA) or Flexible Spending Account (FSA).
• Dental and Vision Insurance: Keep your smile bright and vision sharp with our dental and vision insurance options.
• Company-Paid Life & AD&D Insurance: Gain peace of mind with fully covered basic life and accidental death & dismemberment insurance.
• Company-Paid Disability Coverage: Stay protected with employer-paid short-term and long-term disability plans.
• 401(k) with Company Match: Build your future with Roth and Traditional 401(k) options, plus a company match every pay period.
• Generous Paid Time Off: Enjoy PTO that grows with your years of service.

Northern Illinois Hospice is an equal-opportunity employer. We are committed to the full inclusion of all individuals. We recruit, train, compensate, and promote regardless of race, religion, color, national origin, sex, disability, age, veteran status, and other protected status as required by applicable law. At Northern Illinois Hospice, we believe diversity makes us better.

Northern Illinois Hospice is a drug free workplace.

• Registered nurse with current licensure to practice professional nursing in Illinois.
• Bachelor’s degree in Nursing from an accredited program required. Master’s preferred.
• Minimum of 5 years of progressive clinical leadership in hospice required, preferably in a Joint Commission-accredited program.
• CHPN preferred, or willingness to achieve certification within one year of hire.
• Hospice quality and compliance certification preferred, or willingness to achieve certifications within two years of hire.
• Experience with the palliative programs, in addition to hospice, preferred.
• In-depth knowledge of hospice regulations, including Medicare Conditions of Participation (CoPs) and CMS quality reporting.
• Demonstrated experience in leading quality assessment, process improvement, and compliance initiatives.
• Valid drivers’ license, current auto insurance and access to a reliable automobile.
• Must read, speak, write, and understand the English language.
• Proficiency in quality management software, electronic medical records (EMR), and Microsoft Office Suite.