Clinical Compliance Manager (RN)

Job ID
8:00 AM - 5:00 PM


Responsible for the leadership, continuous quality improvement and growth of the education and clinical systems within each ministry site.  Assists Director of Clinical Operations in ensuring state and federal clinical compliance.  Assists in planning, developing, directing, monitoring and supporting all clinical activities to ensure quality services are provided. 


  • Serves as a valuable resource for the clinical team at each facility. Assists the clinical teams with problem solving. 
  • Uses system generated quality related data (e.g. Point Click Care, QAPI, QA Reader etc.) and safety related data to develop performance/process improvement plans. 
  • Become a subject matter expert (SME) for the Point Click Care software system.
  • Evaluates unanticipated hospital discharges and provides educational opportunities to decrease unavoidable re-hospitalizations.
  • Manages and all facility related compliance with requirements in compliance program/plan.
  • Oversees competency programs and evaluates effectiveness.
  • Manages all self-reportable, facility complaint and facility reportable incidents and provides guidance to facility leadership for the writing of 24 Hour and 5 Day Reports.
  • Assists facility leadership with Plan of Correction (POC) related information and 2567 compliance.
  • Assists Director of Clinical Oversight in the management of all Federal and State compliance related issues.
  • Ensure compliance with new CMS “Requirements of Participation” within skilled nursing facilities.
  • Directs and coordinates root cause analysis(RCA) of safety events. Manages the investigations of serious safety events(SSE). Presents investigations and action plans, including follow up to the appropriate leadership. 
  • Assists the Director of Clinical Operations in developing and maintaining a comprehensive annual mock survey plan for each facility. Participates in the Mock Survey Team. Assists facilities with action plans, audits, etc. to ensure continuous survey readiness. 
  • Continually monitors each facility for regulatory compliance. Prepares and provides guidance to the leadership teams at each facility during licensure surveys.
  • Routinely visit assigned facilities to review/monitor/audit the quality of care provided to residents and attends/participated in assigned facility QAPI Meetings.
  • Assess the knowledge, skills, techniques, procedures, and performance of the nursing staff.
  • Reports findings, conclusions, actions, and plans to clinical services, administrator and /or director of nursing as appropriate
  • Works in conjunction with the Nursing management to initiate and implement clinical process improvement initiatives and educational programming.
  • Review the clinical record documentation for accuracy, timeliness, and applicability.
  • Identify and evaluate areas of concern pursuant to quality resident care, and as it relates to state and federal regulations.
  • In conjunction with the facility director of nursing and/or administrator, assist with the development of action plans to address concerns, correct problems, or implement new/changed procedures.
  • Provide education and in-service training on topics to include but not limited to techniques, procedures, regulations, company policies and other information
  • Monitor ongoing in-service education per facility.
  • Directs interdisciplinary education programs to include clinical, regulatory, compliance, and operational training as it relates to resident nursing care and other medical care educational programs and services.
  • Assists Director of Clinical Oversight in the educational programming based on assessment of clinical competency of licensed and certified staff.
  • Participates in SNF-wide quality improvement initiatives.
  • Assists Director of Clinical Oversight with policy and educational programming as it relates to a changing regulatory environment.
  • Works in conjunction with home office staff regarding ministry site education and provides oversight of the delivery of SNF education in the Relias Online Learning Management System.
  • Has an attitude of continuous learning, connecting with and participating in key related professional organizations and advocacy groups such as AHCA, AANAC, etc. Conducts internal and external research, analyzing and presenting information for consideration in a concise and actionable format. 



  • Registered Nurse licensed in the State of Michigan
  • 10+ years of experience in long term care setting
  • Extensive knowledge/oversight of transitional care/sub-acute units
  • Familiarity and ability to apply data as it relates to the MDS 3.0 and process improvement
  • Thorough understanding of staffing hours per patient day information
  • Understanding of adult learning approaches
  • Knowledge of excel, word and powerpoint applications, Interact II tools

**Keywords:   Wellspring Lutheran Services, Full Time, Registered Nurse, RN, Skilled Nursing, Long Term Care Facility, Fairview, Frankenmuth, Flint, Livonia, Monroe**




Sorry the Share function is not working properly at this moment. Please refresh the page and try again later.
Share on your newsfeed