Summary

Maintain responsibility for all Quality activities of the organization. Accountable for the monitoring, implementation, and evaluation of processes and programs to meet regulatory, accreditation, and standards of practice. Plan, execute, and finalize projects under the guidance of the Vice President of Clinical Operations, including acquiring resources, coordinating efforts of team members, defining objectives, and overseeing quality control throughout projects to ensure completion.  Serves as backup administrator.

Essential Duties and Responsibilities

include the following. Other duties may be assigned as necessary.

• Implement and monitor the organization’s quality assessment performance improvement (QAPI) program
• Direct and coordinate quality improvement activities utilizing continuous quality improvement principles and methodologies
• Ensure that there are processes in place to monitor and measure all activities related to QAPI
• Establish a process model for improvement and provides education and training to organization personnel on QAPI plan and team development
• Coordinate activities related to clinical record review for data collection
• Compile, trend, and report quality data in patient care, safety, risk management, infection control, outcomes, and customer satisfaction
• Collaborate with Nursing Supervisors to ensure documentation is complete and consistent with care and reflects legal requirements
• Ensure processes to monitor and evaluate safety, risk management, and infection control programs
• Coordinate, educate, and implement monitoring activities for safety, risk management, and infection control
• Collaborate with management in follow-up of concerns expressed by patients, families, and physicians
• Maintain current knowledge related to home care safety and infection control standards
• Collaborate with Nursing Supervisors to provide a process to promote and ensure employee orientation, competency, and in-service education programs
• Assist in the identification of skills for annual competence and provide in-service training support
• Collect data on records of employee orientation and annual competency requirements as part of the QAPI plan
• Monitor organization compliance with regulatory and accreditation standards
• Maintain current knowledge related to Medicare Conditions of participation and the Accreditation Commission for Healthcare (ACHC) standards to ensure that the organization is compliant with state, federal, and accreditation guidelines
• Act as a resource to Supervisors regarding standards, policies, and regulations and provide in-service training to leadership and staff as needed in these areas
• Maintain updated nursing knowledge and skills
• Responsible for HCHB workflow related to Quality, pushing admissions and processing discharges
• Assisting with the overall development and implementation of the QAPI program
• Assisting in the identification of goals and related patient outcomes
• Coordinating, participating and reporting of activities and outcomes
• May assist with administrative on-call during after hours, if needed
• Comply with Company’s Core Values and Core Competencies
• Perform other duties as assigned

Administrator Duties

In the absence of the Administrator/ Vice President of Operations, the Director of Regulatory and Quality Assurance will assume/ fulfill the duties of the Administrator. Duties are as follow:

• Be Appointed by and report to the governing body
• Be responsible for all day to day operations of the hospice agency
• Ensure that a clinical manager as described in paragraph (c) of section 484.105(b)(1)of the Conditions of Participation is available during all operating hours.
• Ensure that the hospice agency employs qualified personnel, including assuring the development of personnel qualifications and policies.
• Organizes and directs the hospice services ongoing day to day operations
• Maintains ongoing liaison among owner and personnel
• Ensures adequate personnel education and evaluations
• Ensures the accuracy of public information materials and activities
• Implements an effective budgeting and accounting system
• Available during all operating hours for patient service delivery needs or personnel needs
• All other duties as assigned by the Administrator/ Vice President.

Qualification Requirements

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. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Bachelor’s degree in Nursing required, Master’s preferred
• 3-5 years of experience in healthcare management
• Excellent understanding of performance improvement, quality assessment, and utilization management
• Competency and proficiency in understanding QAPI and ACHC
• Solid working knowledge of current systems
• Demonstrated experience in personnel management
• Experience working both independently and in team-oriented, collaborative environment is essential
• Can conform to shifting priorities, demands, and timelines through analytical and problem-solving capabilities
• Able to respond to project adjustments and alterations promptly and efficiently
• Flexible during times of change
• Strong written and oral communication skills
• Strong interpersonal skill
• Strong customer service skills
• Good team building skills
• Self-directed and able to work with minimal supervision

Certificates, Licenses, Registrations

Must have and maintain in good standing professional license, certificate, or registration, as applicable.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, climb stairs, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

The employee frequently lifts and/or moves up to 20 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Work Environment

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

This job generally operates in a clerical office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets, and fax machines. While performing the duties of this position, the employee may travel by automobile and be exposed to changing weather conditions.

NOTICE: Successful completion of a drug screen prior to employment is part of our background process, which includes medical and recreational marijuana.

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By submitting your application, you are confirming that you are legally authorized to work in the United States.

JR# JR257406