Director of Quality and Clinical Excellence

Audit and Compliance

• Earn accurate and compliant clinical documentation from clinical notes
• Own chart-audit program across inpatient and outpatient settings
• Define audit methodology, including chart sample size, note types reviewed, review cadence, scoring approach, and escalation process
• Coordinate external coding and compliance support
• Lead documentation standardization through templates, macros, Epic, PointClickCare, Haiku workflows, and ambient AI documentation tools
• Perform and oversee audits
• Inform future hiring of audit and compliance staff with appropriate billing and compliance expertise

Clinical Competence

• Ensure practitioners progress toward mastery in serious-illness communication, symptom management, interdisciplinary care, and high-quality palliative care practice
• Define expected competencies at key milestones, such as 3, 6, and 12 months, and establish an ongoing competency review cadence after year one
• Develop a clear scoring scale, such as not yet meeting competence, competent, and exceeding expectations
• Design and oversee direct-observation “ride-along” visits
• Partner with Team Leads, quality team members, and senior clinical leadership to ensure competency reviews are consistent, constructive, and aligned with organizational standards
• Develop scoring tools consistent with the competency framework and build the Team Lead spot-checking quality assurance function as part of the team’s 90-day plan
• Connect competency results to education, coaching, remediation, and professional development in partnership with the Director of Professional Development and Clinical Practice

Outcomes and Performance Measurement

• Evaluate performance against program KPIs, including readmission-risk reduction, fewer unnecessary emergency department visits, increased appropriate hospice utilization, clearly documented advance care planning, and improved patient and family communication and satisfaction
• Evaluate hospital-facing team outcomes, including decreased hospital mortality where applicable and measurable
• Assess the feasibility and value of provider-specific outcome measurement where current measures exist primarily at the hospital or program level
• Develop and implement a patient and family satisfaction measure for the outpatient setting
• Use quality and outcome data to identify trends, gaps, opportunities for improvement, and areas requiring focused education or intervention

Certification and Audit Readiness

• Serve as the internal authority on what must be in place when external auditors, surveyors, payers, or certification bodies arrive
• Operationalize Joint Commission, CHAP, payer, and other applicable certification or audit standards
• Maintain certification readiness as a continuous lens across documentation, competency, performance improvement, facility readiness, and clinical practice
• Maintain the evidence base needed to demonstrate a functioning quality program, including policies, audit results, performance-improvement records, dashboards, committee minutes, and reporting
• Lead preparation for external audits, payer reviews, partner reviews, and certification surveys

Governance and Reporting

• Operate a continuous quality loop: set standards, collect data, audit performance, identify gaps, build action plans, educate, re-audit, and report results
• Lead the NJPCS Quality Committee and recurring quality reviews
• Deliver monthly dashboards and quarterly reports to clinical and executive leadership
• Develop and oversee performance-improvement projects, including project goals, interventions, timelines, responsible parties, and re-audit results
• Track goal attainment and ensure findings lead to measurable improvement, education, remediation, and accountability