Director of Compliance

Job Description

Job Description

Description:

Job Title: Director of Compliance

Department: Altus Community Healthcare; Compliance

Reports To: President; Chairs the corporate Compliance Committee with a dotted-line relationship to the Board of General Partners.

Summary:

The Director of Compliance and Patient Safety is responsible for the design, implementation, and oversight of an enterprise-wide compliance, ethics, quality, and patient safety program across all facilities. This role ensures organizational adherence to applicable federal, state, and local healthcare laws and regulations, accreditation standards, and industry best practices, including but not limited to CMS Conditions of Participation, EMTALA, HIPAA, OSHA, Medicare/Medicaid requirements, and Texas Health &Human Services regulations.

Reporting to President and working closely with ZT Group COO, the Director serves as the principal advisor on compliance and regulatory matters, promoting a culture of integrity, accountability, and ethical decision-making while minimizing regulatory, financial, operational, and reputational risk. The Director leads regulatory readiness, accreditation activities, and enterprise risk assessments, ensuring the organization is prepared for audits, surveys, inspections, and investigations.

The Director partners closely with clinical leadership, medical staff, andoperational teams to develop, implement, and enforce policies, procedures,and internal controls that promote patient safety, regulatory compliance, andcontinuous quality improvement. This role oversees compliance audits, monitoring activities, investigations, incident reporting, and corrective action plans, ensuring timely identification, escalation, and remediation of compliance and patient safety concerns.

Additionally, the Director of Compliance and Patient Safety leads education and training initiatives to strengthen organizational awareness of regulatory requirements, ethical standards, and patient safety expectations. Through data-driven oversight, transparent reporting, and cross-functional collaboration, the Director supports high-quality, patient-centered care while maintaining regulatory integrity, accreditation readiness, and patient trust.

Essential Duties & responsibilities:

Strategic, Executive & Enterprise Compliance Leadership

• Lead an enterprise-wide compliance, ethics, quality, and patient safety program aligned with organizational strategy and regulatory requirements.
• Serve as the primary compliance advisor to the President, Group ZT COO, and governing bodies.
• Establish and maintain a risk-based compliance and governance framework that supports ethical decision-making and regulatory readiness across all facilities.
• Promote a culture of integrity, accountability, and compliance throughout the organization.
• Provide executive leadership and reporting for audit, compliance, and risk oversight, including program effectiveness, investigations, audit results, and emerging risks.
  

• Ensure compliance with applicable federal, state, and local healthcare laws, regulations, accreditation, and licensing requirements.
• Oversee regulatory and accreditation readiness, including surveys, audits, inspections, and investigations.
• Lead enterprise compliance and regulatory risk assessments and development of the annual compliance workplan.
• Identify and mitigate regulatory, operational, financial, and reputational risks.
• Serve as the primary liaison with regulators, auditors, and accreditation bodies.
  

• Develop, implement, and maintain compliance policies, procedures, and standards of conduct across all facilities.
• Oversee risk-based audits, monitoring, and internal investigations, ensuring timely resolution and corrective action in coordination with Legal.
• Monitor and evaluate compliance program effectiveness using metrics, audit results, hotline data, and stakeholder feedback to drive continuous improvement.
• Ensure accurate, complete, and auditable compliance documentation and records.
• Own and maintain centralized oversight of all licensing and registration compliance, including applications, renewals, tracking, and regulatory monitoring; serve as the accountable corporate lead for this function regardless of delegated execution, coordinating cross-functional inputs (legal, clinical, facilities, operations), managing the process through a centralized compliance platform, and ensuring appropriate visibility and control for administrators and regional stakeholders.
  

• Design and oversee QAPI initiatives across clinical and operational areas to improve outcomes and patient experience.
• Use data and key performance indicators to identify gaps in care, compliance, and operational performance.
• Lead analyses of quality, safety, and compliance events and implement corrective actions as needed.
  

• Oversee the organization’s privacy and information protection program, ensuring compliance with HIPAA and other applicable data protection and privacy laws.
• Partner with Information Technology and Health Information Management to safeguard protected health information and ensure effective breach prevention and response protocols.
• Conduct privacy risk assessments and ongoing monitoring activities.
• Oversee the development, execution, and monitoring of Business Associate Agreements and vendor compliance with privacy and security requirements.

• Establish and maintain effective, confidential compliance reporting mechanisms, partnering with HR where relevant, including a hotline that encourages reporting without fear of retaliation.
• Ensure timely review, investigation, and resolution of reported concerns.
• Communicate compliance expectations, trends, and lessons learned across the organization.

Education, Training & Culture of Compliance

• Develop and oversee a comprehensive, risk-based compliance education and training program, including annual, role-based, and targeted training initiatives.
• Deliver and oversee compliance, privacy, quality, and patient safety training for leadership, providers, and staff.
• Promote a culture of ethics, accountability, safety, and continuous improvement through education, leadership engagement, and clear communication.
• Partner with Human Resources and operational leadership to reinforce compliance expectations across clinical, administrative, and operational functions.

Clinical, Operational & Cross-Functional Collaboration

• Collaborate closely with Executive Leadership, Legal, Risk Management, Quality, Internal Audit, Human Resources, Operations, Medical Staff Affairs, and Medical Staff Leadership to ensure a coordinated and integrated compliance approach.

Partner with physicians, nurses, and interdisciplinary teams to improve workflows, reduce variation, and promote evidence-based practices.

Core Competencies

Enterprise Compliance Leadership

Leads and executes an enterprise compliance strategy by translating healthcare regulatory requirements into practical programs, controls, and oversight across clinical and operational functions.

Regulatory, Clinical & Operational Risk Management

Applies strong regulatory and reimbursement knowledge to align compliance, patient safety, clinical quality, and documentation integrity with organizational risk mitigation and audit readiness.

Governance, Ethics & Stakeholder Engagement

Provides ethical and governance oversight, including board engagement, investigations, policy management, and effective collaboration with physicians, leaders, regulators, auditors, and legal partners.

Change Leadership & Continuous Improvement

Adapts compliance programs to evolving regulations and care models while driving continuous improvement, education, and accountability across the workforce.

KPIs

Clinical Quality, Safety & Accreditation

• Trends in patient safety events, complaints, and quality findings
• Compliance with clinical standards and ongoing accreditation readiness

Compliance Program Effectiveness

• Completion and impact of compliance training and education
• Hotline activity, response timeliness, and resolution effectiveness
• Policy adherence and effectiveness of corrective actions

Regulatory, Risk & Audit Outcomes

• Results of regulatory surveys, audits, and inspections
• Severity, remediation, and closure of deficiencies and risks
• Effectiveness of internal controls and investigations

Privacy & Data Protection

• HIPAA and privacy incident trends and breach response effectiveness
• Business Associate compliance and privacy risk management

Workforce Engagement & Governance

• Compliance culture, accountability, and responsiveness
• Execution of the compliance workplan and quality of Board reporting

External Relations & Reputation

• Effectiveness of regulator and auditor interactions
• Reduction in compliance-related reputational risk

Accreditation Compliance

• Ensure all applicable facilities maintain required accreditation by overseeing CHIQ/state survey readiness, managing corrective action plans, and driving timely resolution of any findings to achieve and sustain full compliance.

Marginal Duties

Additional Responsibilities:

• Attend Board, committee, and executive leadership meetings.
• Maintain a visible leadership presence through quarterly attendance at community and healthcare-related events, supporting community engagement, organizational reputation, and strategic growth initiatives.
• Ensure emergency preparedness, business continuity, and disaster recovery plans are maintained and updated.
• Perform additional duties as assigned by theGroup ZT COO.

Qualifications:

Education and/or Experience:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

Education & Experience

• Bachelor’s degree in nursing, Healthcare Administration, Public Health, or a related field (required).
• Master’s degree in healthcare administration, Nursing, Quality, or a related field (preferred).
• RN license (if applicable) preferred.
• Certification in Healthcare Quality (CPHQ) and/or Patient Safety (CPPS) strongly preferred.
• Five (5) or more years of progressive experience in healthcare quality, compliance, and/or patient safety.
• Two (2) or more years of experience in a leadership role within a healthcare organization.
• Demonstrated experience with regulatory surveys and inspections (e.g., CMS, CIHQ, accreditation bodies), quality improvement methodologies (Lean, Six Sigma), and healthcare data analytics.

Skills

• Strong knowledge of healthcare regulatory and accreditation standards, including CMS, The Joint Commission (or other accrediting bodies), and OSHA.
• Excellent leadership, communication, and problem-solving skills, with the ability to influence across clinical and operational teams.
• Proficiency in quality and compliance management tools and systems, including QAPI programs, dashboards, auditing tools, and root cause analysis methodologies.
• Ability to analyze data, identify trends, and translate findings into actionable improvement strategies.
• Demonstrated commitment to ethical leadership, regulatory integrity, and patient-centered care.

Physical Demands

The physical demands described herein are representative of those required to successfully perform the essential functions of this role. Reasonable accommodations may be made to enable individuals with disabilities to perform these essential functions.

• Ability to sit, stand, walk, and move throughout hospital and office environments as needed.
• Ability to use hands and arms to perform tasks requiring reaching, handling, and operating standard office equipment.
• Ability to occasionally lift or move light objects as necessary to perform job duties.
• Ability to work extended hours and respond to operational or clinical matters outside of normal business hours, including on-call or emergency situations as required.

Work Environment

The work environment characteristics described herein are representative of those an employee encounters while performing the essential functions of this role. Reasonable accommodations may be made to enable individuals with disabilities to perform these essential functions.

• Work is primarily performed in an office setting within a healthcare facility environment.
• Role operates in a fast-paced, high-accountability environment requiring sound judgment, critical thinking, and timely decision-making.
• Travel is required for facility visits, industry meetings, partnerships, and other business-related activities.