Director of Clinical Quality

Summary

The Director of Clinical Quality oversees the development, implementation and maintenance of the quality management program for Hospice and Palliative Care.

• Develops a Quality Assurance/Performance Improvement (QAPI) Plan for Hospice consistent with regulatory requirements, industry standards and patient needs.
• Keeps senior leadership abreast of trends within healthcare quality, the impact on hospice, advises and recommends strategic quality initiatives.
• Reports on key quality indicators to Senior Leadership.
• Collaborates with leadership and hospice staff to develop clinical performance indicators, manage related analysis and benchmarking, and disseminate information. Ensures quality and performance improvement data is used for statistical data and performance improvement.
• Facilitates data collection and analysis, identifies trends and partners with management to develop corrective action plans.
• Collaborates with clinical and operational departments to ensure implementation of interventions.
• Works collaboratively with the CEO in the development and evaluation of the Q1 program and evaluation in accordance with the organization's mission, goals, and federal and state regulations.
• Works to ensure data reporting needs are met.
• Ensures effective analysis of performance metrics in comparison to internal/external benchmarks and goals.
• Identifies opportunities for improvement and ensures appropriate interventions are implemented and evaluated.
• Ensures consistent development, implementation and accountability of performance improvement initiatives to enhance processes that support the provision of high‑quality care and ensures effectiveness of performance improvement projects.
• Maintains knowledge of current trends and developments in areas of responsibility through membership in appropriate professional organizations, attending in‑services and continuing education to maintain current knowledge of expertise and up‑to‑date knowledge of laws, regulations and payer requirements that affect policy and procedure.
• Oversees CMS Hospice Quality Reporting Program (CAHPS and HIS) to ensure compliance with regulatory mandates.
• Assists in maintaining survey readiness, including mock surveys, chart reviews, and compliance follow‑up.
• Utilizes data to implement Performance Improvement Projects in order to improve practice and service.
• Reviews performance data, identifies trends and partners with management to develop corrective action plans.

• RN degree required; bachelor's degree in nursing preferred.
• Two years' previous managerial experience preferred; experience in Hospice/Home Health service industry required.
• Strong communication skills and collaboration skills.
• Familiarity with state and federal guidelines and regulations.

• Valid driver's license and automobile liability insurance coverage.
• Unencumbered and active RN license in state of residence required if RN.

• Intermediate Excel skills.
• Basic PowerPoint skills.
• Experience in reviewing data in electronic systems required.
• Experience with Hospice/Home Care required.

Subject to a post employment background check and drug screening as a condition of employment.