Job Description

Job Summary:

Responsible for maintaining compliance with all State, Federal regulatory guidelines and third party payers; Accreditation standards and quality activities of the organization. Provides leadership and expertise to facilitate and support staff competency through best practice teaching, consultation, collaboration and the use of current knowledge, research and technology.

Essential Functions:

• Ensures that there are processes in place to monitor and measure all activities related to quality assessment and performance improvement (QAPI).
• Provides direction and coordination of quality improvement activities utilizing continuous quality improvement principles and methodologies. Provides education and training to organization personnel on the QAPI plan, and team development.
• Performs clinical record review activities for data collection.
• Compiles, analyzes, trends and reports quality data in the following areas: hospice & palliative care quality reporting, patient care, safety, risk management, infection control, outcomes and customer satisfaction.
• Works collaboratively with nursing supervisors/managers/directors to assure documentation is complete and consistent with care and reflects legal requirements.
• Promotes professional standards of care, compliance with regulatory requirements, third-party payor reimbursement models, and organization policies and procedures through use of performance improvement methodology.
• Ensures complete responses to Additional Development Requests (ADRs), Comprehensive Error Rate Testing (CERT), Recovery Audit Contractor (RAC) etc., requests and participates in appeal processes.
• Participates in the development and annual revision of Quality Assessment and Improvement Plans and Program Evaluation.
• Participates in analyzing, developing, coordinating and implementing plans of correction for noted deficiencies.
• Makes recommendations to the education committee for mandatory education related to accreditations and compliance topics.
• Acts as a mentor and resource for staff with regard to performance improvement methodology, regulatory, educational and patient care issues.
• Participates in the evaluation, development and revision of policies and procedures for hospice.
• Participates on various committees related to Organizational Quality and Education.
• Maintains professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal and professional networks.
• Adheres to organizational Code of Conduct, policies, procedures, protocols and processes and all regulatory and legal requirements
• Adheres to the C.A.R.E. Model of Service: courtesy, acknowledgement, response and empathy.

Qualifications :

• Registered Nurse with a baccalaureate degree in nursing, preferably a Master’s Degree in a health-related discipline. Minimum three (3) years’ direct hospice experience may be considered in lieu of BSN degree.
• Requires two to three years related quality and accreditation experience.
• Current RN licensure in State of Michigan and maintain such licensure in accordance with applicable laws and regulations and perform within the scope specified.
• Extensive knowledge of Hospice regulations and standards preferred.
• Excellent written, verbal and interpersonal skills necessary to interact with a wide variety of staff.
• Is self-directed and able to work with minimal supervision.
• Requires knowledge of quality assessment and utilization review functions, principles and practices.
• Theoretical and practical knowledge of principles of adult learning and ability to develop and present educational programs.
• Quantitative, analytical and computer skills to collect, analyze, display and present data.
• The physical and sensory demands of the position include: vision, effective speech and hearing for extensive telephone contact; repetitive motion; traveling; driving or riding in motor vehicle; standing, sitting, walking, bending, reaching, and stretching; lifting up to forty five (45) pounds unassisted and the ability to assist in lifting patients using appropriate lifting techniques and/or devices.
• Must be able to work variable hours/shifts and/or days, including weekends. Must have ability to occasionally work extended days.
• Must be eligible to work in the United States.

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