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. The role supports quality improvement initiatives by monitoring performance trends, identifying gaps, and helping implement corrective action as needed. It also oversees compliance-related activities to support accreditation readiness, regulatory standards, and consistent clinical practice. In addition, the position manages budget-related responsibilities, supports financial stewardship, and partners with clinical, operational, and executive leaders to align program goals, quality outcomes, and long-term business priorities.
Education:
Bachelor’s degree in nursing required. Master’s degree or advanced coursework in healthcare administration or related field preferred
Experience:
- 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)
Certification & Licensures:
Current state Registered Nurse or Nurse Practitioner License 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
Principal Duties & Responsibilities:
Quality & Compliance
- 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.
- Monitor patient safety trends and support initiatives that reduce risk, improve outcomes, and strengthen clinical practice.
- Maintain awareness of regulatory changes and communicate potential operational or compliance impacts to leadership.
Education & Clinical Effectiveness
- 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.
- Support onboarding, annual competencies, and ongoing education to ensure staff are prepared to meet clinical and regulatory expectations.
- 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.
Leadership & Collaboration
- Serve as a developing leadership role within the joint venture, with scope that may evolve as program needs and staffing structure grow.
- Support and coach clinical leaders to strengthen accountability, quality ownership, and team performance.
- Collaborate with operations, finance, clinical leadership, and senior leadership to align quality, compliance, education, and organizational goals.
- Serve as a resource to leaders and staff regarding quality standards, compliance expectations, patient safety, and performance improvement.
- 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.
Operations & Financial Stewardship
- 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.
Strategic Growth
- Partner with the overall leadership team on strategic planning, program development, and growth initiatives.
- Serve as the quality leader and subject matter expert for joint venture initiatives involving clinical quality, compliance, patient safety, and education.
- Support development of quality infrastructure as the joint venture expands, including processes, reporting, education, and accountability structures.
- Provide insight on regulatory, compliance, and patient safety considerations related to program growth or service expansion.
- Collaborate 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.
All roles must demonstrate Gilchrist-Inova Values
Value Description
Respect
I will treat everyone with courtesy. I will foster a healing environment.
- Treats others with fairness, kindness, and respect for personal dignity and privacy
- Listens and responds appropriately to others’ needs, feelings, and capabilities
Excellence
I will strive for superior performance in every aspect of my work. I will recognize and celebrate the accomplishments of others.
- Meets and/or exceeds customer expectations
- Actively pursues learning and self-development
- Pays attention to detail; follows through
Accountability
I will be professional in the way I act, look and speak. I will take ownership to solve problems.
- Sets a positive, professional example for others
- Takes ownership of problems and does what is needed to solve them
- Appropriately plans and utilizes required resources for various job duties
- Reports to work regularly and on time
Teamwork
I will be engaged and collaborative. I will keep people informed.
- Works cooperatively and collaboratively with others for the success of the team
- Addresses and resolves conflict in a positive way
- Seeks out the ideas of others to reach the best solutions
- Acknowledges and celebrates the contribution of others
Ethical Behavior
I will always act with honesty and integrity. I will protect the patient.
- Demonstrates honesty, integrity and good judgment
- Respects the cultural, psychosocial, and spiritual needs of patients/families/coworkers
Results
I will set goals and measure outcomes that support organizational goals. I will give and accept help to achieve goals.
- Embraces change and improvement in the work environment
- Continuously seeks to improve the quality of products/services
- Displays flexibility in dealing with new situations or obstacles
- Achieves results on time by focusing on priorities and manages time efficiently
Pay Range
Final salary offer will be based on the candidate's qualifications, education, experience and alignment with our organizational needs.
Equal Employment Opportunity
Gilchrist Inova and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.
