Quality Field Director - Gilchrist Inova

About the role

The role provides leadership support for the strategic growth and operational development of the joint venture, with responsibility for designing and delivering ongoing education that supports patient experience, clinical quality, staff competence, regulatory compliance, and patient safety.

Responsibilities

• Lead and monitor the Quality and Compliance Program for the Gilchrist-Inova joint venture.
• Ensure compliance with Medicare, Medicaid, CHAP, and applicable federal, state, and local regulatory requirements.
• Develop, monitor, and report on quality indicators, performance improvement metrics, audit findings, and compliance trends.
• Identify areas of risk or underperformance and partner with leadership to develop corrective action plans.
• Respond to quality concerns, conduct reviews and risk assessments, and implement education and corrective action as needed.
• Support accreditation readiness activities, including policy review, documentation standards, staff preparation, and survey response.
• Maintain awareness of regulatory changes and communicate potential operational or compliance impacts to leadership.
• Assess learning needs and design education programs that support patient experience, clinical quality, staff competence, regulatory compliance, and patient safety.
• Develop and deliver ongoing education related to regulatory changes, documentation standards, quality expectations, and clinical best practices.
• Promote evidence-based practices and continuous improvement in end-of-life care.
• Partner with clinical leaders to identify staff knowledge gaps and develop targeted training or reinforcement plans.
• Evaluate the effectiveness of education programs through feedback, performance trends, audit outcomes, and quality indicators.
• Provide education related to documentation quality, care standards, compliance expectations, and patient-centered service delivery.
• Serve as a developing leadership role within the joint venture, with scope that may evolve as program needs and staffing structure grow.
• Collaborate with operations, finance, clinical leadership, and senior leadership to align quality, compliance, education, and organizational goals.
• Facilitate cross-functional problem solving and help ensure consistent communication across clinical, operational, and administrative teams.
• Model organizational values and foster an inclusive, accountable, and high-performing work environment.
• Support a culture of continuous improvement, shared accountability, and service excellence.
• Lead quality budget development and monitor program efficiency, resource utilization, and operational needs for the Gilchrist-Inova joint venture.
• Support financial stewardship by aligning quality, compliance, and education initiatives with available resources and organizational priorities.
• Partner with Finance and operational leaders to understand budget impact, staffing needs, program expenses, and resource allocation.
• Support education related to reimbursement, documentation, and revenue cycle processes in partnership with Finance.
• Identify opportunities to improve workflow efficiency, reduce duplication, and support sustainable program operations.
• Monitor quality and compliance activities that may impact reimbursement, regulatory performance, patient outcomes, or operational risk.
• Provide input into program planning, budget needs, and resource requests related to quality, compliance, education, and patient safety.
• Partner with external partners, accrediting bodies, and community stakeholders as needed.
• Support leadership in evaluating program performance, identifying improvement opportunities, and preparing for future operational needs.
• Contribute to long-term planning by helping ensure quality, compliance, education, and financial stewardship are integrated into growth decisions.

Qualifications

• Bachelor’s degree in nursing required.
• Master’s degree or advanced coursework in healthcare administration or related field preferred.
• Minimum of seven years of experience in hospice, palliative care, or oncology.
• Demonstrated leadership experience in quality, compliance, or clinical operations.
• Direct experience with regulatory and accreditation agencies (Joint Commission or CHAP required).

Skills

• Independently creates and manages a system and structure of continuous accreditation preparedness.
• Ability to develop and lead mock surveys and audit organizational compliance against COPS and accreditation standards.
• Ability to perform periodic field visits to assess organizational compliance to regulations and policies and procedures, and follow-up with operational leaders as needed.
• Ability to develop and track performance dashboards.
• Ability to identify patient feedback, key drivers of experience along with targeted staff training to refine interventions and sustain gains.
• Ability to monitor the venture incident reporting system to drive the development and implementation of improvement plans.
• Ability to assist in the development of plans of correction as necessary.
• Ability to act as a member of the survey team for all state and accrediting surveyors.
• Ability to organize onsite survey requests for information and documentation including scheduling patient visits and interviews with staff.
• Ability to manage a library of policies and procedures consistent with healthcare system requirements including annual review, posting to intranet, supporting staff in the development of new policies and channeling drafts through the proper groups.
• Mastery of Microsoft Office, including Outlook, Word, Excel, and PowerPoint.
• Skilled in written and oral business communication.