Position Summary: The Quality & Compliance Manager coordinates the Compass Regional Hospice (Compass) QAPI program and serves as the Privacy Official and Security Official.
Reports To: Director of Clinical Services
Supervisory Responsibilities: This position supervises the Quality Improvement Assistant, Medical Records Coordinator, and Medical Assistant.
Responsibilities and Functions:
- Evaluates organization’s performance via performance improvement program, productivity, quarterly and annual review assures for the quality and safe delivery of hospice services provided through the organization.
- Maintains compliance with Medicare Regulations and accrediting bodies as appropriate.
- Monitors patient clinical records concurrently and retrospectively, utilizing established outcome criteria, i.e., measures within software system and care plan.
- Maintains compliance with CMS Quality Reporting Requirements.
- Leads the Quality & Compliance Committee.
- Facilitates Performance Improvement teams.
- Coordinates data collection for benchmarking purposes.
- Functions as a clinical resource to all staff.
- Assesses, plans, implements and evaluates the performance improvement programs of the organization.
- Develops, assists and/or coordinates the development of performance improvement studies as requested by the Leadership.
- Assists in the analysis of needs and resources of Compass and in the formulation and development of goals and plans for Compass.
- Serves as the Compliance Officer, Privacy Officer and Risk Manager for Compass and Civil Rights Officer for patients.
- Reviews, revises, and implements policies and procedures to maintain compliance with State and Federal Regulations and other accrediting bodies.
- Maintains the confidentiality of employees, patient/client, and agency information at all times.
- Performs other related duties and responsibilities as required.
- Serves as Emergency Planner.
- Monitors all ADRs and collaborates with the Director of Clinical Services to submit appropriate documentation in a timely manner.
Qualifications:
- Must be a Registered Nurse from an accredited college or university.
- Currently licensed as a Register Nurse in the State of Maryland or possess a compact license transferable to the State of Maryland.
- Must have 3-5 years clinical nursing experience, preferably in hospice
- Experience in management and supervision is preferred
- Good oral and written communication skills
- Experience in QA, CQI, or PI required
- Knowledge of requirements and regulations for the provision of Hospice care
- Complies with accepted professional standards and practice
- Self-directed with the ability to work with little supervision
- Flexible and cooperative in fulfilling role obligation
Requirements:
- Complete hospice orientation.
- Support the hospice concept of care.
- Be flexible and able to work on several projects simultaneously.
- Be able to work harmoniously with many diverse types of individuals and groups.
- Advances knowledge and skills; attends in-services and workshops as appropriate.
- An ability to cope with the stress of continual loss.
- Possesses physical ability to perform job-related duties which may require lifting, standing, bending, transferring, stooping, stretching, walking, pushing, partial or complete assistance with activities of daily living without assistance from another health care worker or significant other.
- Must be able to hear to process directions and requests from doctors, employees, patients, and other individuals.
- Must complete Hospice and Palliative Care Certification (HPCC) within 24 months of hire date.
Work Scheduling:
- Monday – Friday 8:00am – 4:30pm
- Must be flexible to cover patient/staff needs of Compass.
- Must rotate through Administrator on Call schedule.
FLSA Status: This is a full-time position and is classified as exempt under the Fair Labor Standards Act.
