Department: Quality Improvement and Utilization
Reports To: Director of Rehab, Palliative Care, and QAPI/Clinical Manager
Position Summary:
The purpose of this position is to assess, monitor, and advance Hospice clinical practices, focusing on compliance, documentation, CMS requirements for quality reporting operational procedures and case management using the processes of Quality Improvement, Utilization Review and critical thinking. This person works in collaboration with the Director of Rehab, Palliative Care, and QAPI/Clinical Manager and Director of Patient Care Services Hospice to assure compliance with licensing and accreditation requirements, Medicare Conditions of Participation, the California Hospice Standards and LMVNA’s policies and procedures.
Essential Job Functions:
· Assists with the development and implementation of standards and quality improvement mechanisms that assures safe quality services to patients and their families and to improve clinical outcomes when needed.
· Responsible for communication and being knowledgeable in all regulatory, compliance and CMS updates for the hospice department. Assist in implementing processes to assure compliance with new regulatory changes.
· Act as Hospice Quality Assurance and Performance Improvement Director Designee in the absence of the QAPI Director.
· Monitors quality and completion of documentation by Hospice clinicians and implements strategies to improve clinical documentation and meet the standards of the various accrediting and regulatory bodies.
· Audits for hospice delivery of care via chart review and field visits.
· Effectively utilizes the CMS quality reporting measures and patient/caregiver satisfaction surveys.
· Participates in team-based orientation of new staff. Provides education to new hires for hospice on documentation and delivery of care. When requested, fulfills the role of hospice preceptor.
· Uses data from a variety of internal and external sources to assist in the evaluation of the processes and patient outcomes and in identifying and prioritizing opportunities for improvement.
· Uses available data to track utilization of clinical services and impact outcomes. Create and update the CTI as necessary from a clinical prospective and be a resource to the hospice clerical department for the completion of the CTI. Provides oversight throughout the hospice length of stay for continuity of care, following of the IDG care plan and utilization of appropriate disciplines.
· Provides input and participates in ongoing staff competency and evaluation of performance with the Director of Patient Care Services Hospice.
· Exemplifies a collaborative attitude and demonstrates: 1) ability to function as a consultant, 2) ability to role model integrity, compromise, and professional self-confidence.
· Promotes and facilitates understanding of the fiscal impact of all clinical practices and documentation.
· Actively participates as one of the clinical liaisons between electronic medical records, the IT department, and the hospice department.
· Maintains a positive, professional, and respectful attitude.
· Performs other duties assigned and complies with all policies of LMVNA.
Qualifications and Requirements:
· Registered Nurse with current California RN License (BSN preferred)
· Certification in Hospice and Palliative Care preferred
· Two to three years of hospice practice preferred
· Comprehensive knowledge of the Medicare Conditions of Participation for hospice, the California Hospice Standards and The Joint Commission
· Demonstrates collaborative attitude and skill in problem solving
· Proficient computer skills
Physical Demands Required to Perform Essential Job Functions:
The conditions herein are representative of those that must be met by an employee to successfully perform the physical demands of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions.
Environment: Work is performed primarily in a standard office environment.
Physical: primary functions require sufficient physical ability and mobility to work in an office setting.
Occasionally = 1 – 33% Frequently = 34 – 66% Constantly = 67 – 100% of the time
· Must be able to see in the normal visual range with or without correction doing close eye work.
· Grasping: Right – simple grasp frequently
Left – simple grasp frequently
Simple grasp = under 50 lbs. Firm Grasp = over 50 lbs.
Environmental Requirements (possible exposure to):
· Blood/body fluids frequently
· Working with moving machinery/equipment; i.e., Hoyer lift occasionally
· Aerosol transmissible diseases frequently
Other potentially infectious material (OPIM) occasionally
Job Type: Full-time
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