Job Description

Qualification Requirements

• Bachelor’s degree at an accredited school preferred.
• 2 to 5 years performance improvement experience with working knowledge of quality improvement processes, performance measurement and data reporting applications.
• 3 years of leadership experience required.
• Strong knowledge of the requirements for the provision of Hospice care through CMS, Joint Commission, and state regulations.
• Possesses strong organizational and time management skills; possesses the ability to work under pressure and meet multiple deadlines.
• Possesses strong analytical skills.
• Possesses strong verbal and written communication skills.
• Expertise in data management software including spreadsheet development and use.
• Has the ability to work independently and within an interdisciplinary team
• Understands the hospice philosophy.

Essential Job Responsibilities

• Directs and supervises quality and compliance projects to meet agency goals, including monitoring of policies, procedures, activities, external accreditation, and state/federal regulations. Reviews OIG and HIPAA risk reports.
• Provides oversight and direct supervision of the Manager of Health Information Management, Infection Control Nurse and the Compliance Coordinator.
• Ensures audit and compliance activities are conducted with appropriate coordination and feedback from department leaders.
• Serves as chair of the QAPI Oversight Committee, provides oversight of committee documentation and QAPI reports, and arranges meetings to meet at least quarterly to review progress of agency PI goals. Maintains minutes for PI meetings and distributes to the members of the PI Committee.
• Assists QAPI teams with the implementation of the agency-wide QAPI program and facilitates reporting to the QAPI Oversight Committee.
• Follows up on occurrences reported through the agency reporting system, ensures appropriate follow-up and corrective action. Monitors occurrence trends for organization-wide concerns and implements appropriate actions in response to identified concerns.
• Follows up on sentinel events and disasters by performing root cause analysis; prepares summary reports as appropriate.
• Compiles information for reporting to the Clinical Quality and Compliance Committee.
• Compiles and sends Family Satisfaction Survey data to NHPCO and reports to supervisor and Executive Team on quarterly results.
• Oversees the agency compliance program and works with all departments to maintain adherence to the agency compliance policies.
• Advises the CEO on compliance issues and concerns.
• Serves as the agency contact for Joint Commission and state licensing bodies.
• Provides education on corporate compliance for new employee orientation and staff as needed.
• Communicates updates and revisions in standards and regulations to leadership.
• Arranges annual review of Policies and Procedures to ensure that they are current and in compliance with standards and regulations. Coordinates updates to current policies with appropriate departments and initiates new policies when needed. Summarizes policy changes for presentation to the Governing Body.
• Attends staff meetings and completes all mandatory training.
• Holds in strictest confidence all patient information and discloses information and data only to persons authorized by Hospice.
• Oversees the Infection Control Program and provides direct supervision of assigned staff.
• Holds assigned employees accountable to established agency performance standards. Provides regular performance feedback and conducts annual performance evaluations.
• Conducts monthly staff meetings and ensures the effective and positive communication of agency information and goals.
• Responsible for ensuring self and staff learn and utilize technology made available by the agency to increase efficiency, communication and performance of duties.