Chapters Health

Compliance Specialist (RN)

Job ID
2510 HPH Compliance Quality and Risk
Full Time Regular


As a compassionate non-profit organization since 1983, Chapters Health System is committed to enhancing the lives of those affected by advancing age or illness. Through our comprehensive system of healthcare choices, we deliver expert care and heartfelt support to guide the community during the aging and end-of-life journey.  From hospice and palliative care for adults and children suffering with life-limiting illnesses to in-home and community-based services for frail but independent seniors, Chapters Health offers a wide range of support services along life's ever-changing landscape.


The Compliance Specialist supports the Compliance Officer at HPH in implementation of the Compliance program.

This position is responsible at the direction of the Compliance Officer for managing the implementation and daily operations of the Compliance program which supports HPH commitment to ethical conduct and compliance with applicable laws and regulations.



  • Bachelor’s degree required in nursing/health care or other job-related field; Master’s Degree in healthcare field preferred
  • 2-3 years’ related experience with knowledge of regulatory compliance and previous audit experience preferred
  • Certification in health care compliance preferred.

Excellent oral and written communication skills and ability to positively and effectively involve all levels of staff in the organization.

  • Excellent problem solving skills and ability to lead and facilitate group decision-making resolution.
  • Valid Florida Driver's license and auto insurance per Company policy.
  • Able to travel to off site locations.
  • Able to work with minimum supervision and exercise a high degree of discretion and independent judgment.
  • Able to prioritize multiple job responsibilities.
  • Advanced computer skills to include Excel; Visio; Crystal; Power Point; Word.
  • Familiarity with Joint Commission Standards, CMS and AHCA regulations, etc.
  • Familiarity with clinical documentation requirements and electronic medical records.

Job Specific Responsibilities:

  • Develop, implement and revise policies and procedures to comply with applicable regulatory requirements.
  • Develop, coordinate and deliver training to employees, volunteers, interns, contractors and others on HPH's compliance program, policies and other issues, as identified.
  • Implement and manage HPH's compliance and auditing plan.
  • Conduct compliance investigations under direction of Compliance Officer.
  • Review current and proposed HPH programs, services and partnerships to identify and mitigate compliance risks including, but not limited to, HIPAA and Anti-Kickback Statute.
  • Collaborate with other functional areas to modify processes to address identified risk.
  • Monitor, track and report new and ongoing HPH compliance activities.
  • Manage day to day operation of the compliance programs.
  • Respond to and track calls/inquiries from the HPH Compliance Hotline or email.
  • Serve as a resource to ensure that compliance issues and concerns are appropriately evaluated, investigated, and resolved.
  • Other duties as assigned by Compliance Officer.


Compliance Management

  • Assists the Compliance Officer and Risk Specialist in developing and implementing programs designed to improve patient safety and reduce incidents involving patients and visitors.
  • Collects, analyzes and trends data on patient incidents utilizing the event reporting system.
  • Monitors events reported in event reporting system and investigates adverse events as necessary.
  • Facilitates root cause analyses of adverse events and near misses and participates in development of action plans; monitors implementation and outcome of action plans in conjunction with Compliance Officer.
  • Utilizes acquired knowledge from analyses, investigations and root cause analyses to monitor process improvements in safety and risk initiatives.
  • Completes failure effects analysis (FMEA) as appropriate for a high-risk process and the redesign, testing, implementation, and evaluation of the redesigned process.
  • Responsible for thoroughly investigating patient incidents, conducts root cause analyses and develops and facilitates the implementation of action plans.
  • Ability to identify topics for educational sessions; plan and develop educational material and present materials to a wide range of staffing levels.
  • Ability to access, input, retrieve, and operate a variety of computer-based programs, including incident reporting systems.
  • In collaboration with the Compliance Officer, develops strategic initiatives related to patient and staff safety.


Data Management

  • Assures the accurate and timely collection of data related to risk occurrences, safety and health issues and customer complaints.
  •   Utilizes statistical tools to analyze and display data.
  • Monitors data collection process to ensure objectivity of the results.
  • Examines the data elements collected to ensure the data is appropriate and accounts for the information needed to make decisions.
  • Collects and aggregates data; utilizes appropriate statistical tools. Interprets data and analyzes results for validity and significance.
  • Prepares Ethics Point Report for submission to Compliance Officer and Risk Specialist.
  • Monitors patient/family and other customer satisfaction data and  satisfaction database to assess risk and safety vulnerabilities
  • Provides satisfaction survey data to outside agencies to enable benchmarking with other hospices.


Orientation and Education

  •  Develops annual education; provides interim education on related topics as needed.
  •  Assists in providing education for all departments and services relative to Compliance and Risk.
    • Interfaces with Clinical Educators to provide required education of staff related to Compliance/Risk during orientation, annually, and as needed.
    • Revises internal processes and updates forms and procedures used for Compliance/Risk as needed or to keep current with regulatory requirements.
    • Provides for the initial orientation for all staff related to Compliance and Risk management issues.


Specific Activities

  • Works with legal counsel to coordinate the investigation, processing, and defense of claims against the facility; records, collects, documents, maintains, and provides to defense attorneys any requested information and documents necessary to prepare testimony in pending litigation.
  • Responds to professional liability and facility liability questions posed by physicians, nurses, and other personnel.
  • Recommends appropriate revisions to new or existing policies and procedures to reduce the frequency of future occurrences; recommends ways to minimize risks through system changes; reviews and revises facility policies as appropriate to maintain adherence to current standards and requirements.


Professional Development  

  • Enhances professional expertise through attendance at national, state and local conferences.
  • Participates in appropriate professional or specialty organizations through membership and attendance at    local meetings.








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