Director of Clinical Compliance

Job Title/Position: Director of Clinical Compliance

Reports To: Regional Director of Clinical Services

Location: Billings, Montana

• Treat Every Patient and Teammate Like a Loved Family Member
  
• Do What is Right
  
• Find a Way to Say Yes
  

• Health Insurance
• Dental and Vision Insurance
• 401k Retirement Plan
• 100% match up to 4%
• No vesting period
• Paid Time Off (PTO)
• Accrual of PTO starts immediately
• Flexible Work Schedule with Work/Life Balance
• Stillwater University for learning and development

Position Summary:

The Director of Clinical Compliance serves as the organizational lead for regulatory compliance, quality assurance, and clinical integrity across all Stillwater Hospice locations. This position ensures consistent adherence to hospice Conditions of Participation (CoPs), state-specific regulations, accreditation standards, and internal policies.

This role is both strategic and operational—responsible for establishing systems that protect the organization from risk, sustain regulatory readiness, and ensure that patients and families consistently receive compassionate, high-quality care aligned with Stillwater's mission and values.

Key Responsibilities:

1. Regulatory Compliance & Oversight

• Maintain expert-level knowledge of CMS Conditions of Participation (CoPs), state regulations, and accreditation standards (CHAP, ACHC, or Joint Commission).
• Lead ongoing internal compliance audits and chart reviews across all markets, ensuring documentation accuracy, timeliness, and regulatory alignment.
• Coordinate and oversee external audits, surveys, and accreditation reviews; prepare staff and leadership for survey readiness at all times.
• Identify areas of vulnerability and implement corrective action plans; monitor outcomes to ensure sustainable improvements.
• Collaborate with Streamline Business Consultants to align policies, procedures, and clinical protocols across multi-state operations.

2. Quality Assurance & Performance Improvement (QAPI)

• Direct the QAPI program and ensure measurable improvement in patient outcomes, staff performance, and satisfaction metrics.
• Analyze data from HIS/HOPE, CAHPS, and other clinical indicators to identify trends and develop targeted interventions.
• Facilitate monthly quality meetings and coordinate interdisciplinary participation.
• Ensure all QAPI reporting meets federal and state submission timelines and documentation standards.

3. Education & Training

• Develop and deliver training programs on compliance, documentation standards, CoPs, HIPAA, and ethical practices.
• Create market-specific onboarding modules for new clinical leaders in collaboration with Streamline's education and HR teams.
• Support staff competency validation, survey preparation, and continuous learning initiatives.
• Mentor regional and branch clinical leaders to promote a culture of compliance and excellence.

4. Risk Management

• Proactively monitor, investigate, and resolve potential compliance issues, adverse events, and grievances.
• Partner with Human Resources and Executive Leadership to ensure fair, consistent, and compliant resolutions.
• Maintain a confidential system for reporting compliance concerns and ensure timely follow-up.
• Provide executive reports summarizing trends, risks, and corrective actions

5. Clinical Leadership & Collaboration

• Work closely with Regional Directors of Clinical Services and agency Directors of Clinical Services to ensure standardized clinical practices.
• Conduct targeted chart reviews and clinical assessments to ensure patient care aligns with regulatory and organizational standards.
• Serve as a clinical compliance resource for new hospice markets developed under Streamline Business Consultants.
• Participate in leadership strategy meetings to align compliance initiatives with growth and operational goals.

Qualifications:

• Education: Bachelor's degree in Nursing (BSN) required; Master's in Nursing, Healthcare Administration, or related field preferred.
• Licensure: Active, unrestricted Registered Nurse (RN) license in one or more of Stillwater's operating states (Montana, Wyoming, South Dakota).
• Experience:
• Minimum 3 years of hospice or home health clinical experience.
• At least 1 year of experience in compliance, quality management, or leadership within hospice operations.
• Knowledge:
• Deep understanding of hospice CoPs, Medicare regulations, and multi-state licensing requirements.
• Proficiency in survey preparation, accreditation, and QAPI program design.
• Familiarity with EMR systems and documentation workflows.
• Skills:
• Strategic thinker with exceptional attention to detail.
• Strong leadership, communication, and presentation skills.
• Ability to manage multi-site teams and balance competing priorities.

Core Competencies:

• Regulatory and Clinical Expertise
• Quality Improvement and Data Analysis
• Leadership and Mentorship
• Ethical Decision-Making
• Strategic Compliance Planning
• Risk Mitigation and Corrective Action Execution

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