Manager of Quality and Performance Improvement - RN
About The Position
The Manager of Quality and Performance Improvement is responsible for developing, implementing, and maintaining an effective, ongoing, data-driven clinical quality assessment and performance improvement program. The program focuses on indicators that improve clinical outcomes in patient and family care and on activities that affect patient health and safety. The role reviews and oversees clinical documentation to ensure quality of care and compliance with Conditions of Participation, state regulations and licensing requirements, and local coverage determinations. It assists with Quality Assurance and Performance Improvement (QAPI) activities, which may include the 120-Day Report, Quarterly Record Review, and QAPI initiatives for inpatient and home hospice settings, in coordination with others. The position oversees the timeliness and completeness of Plans of Care/Treatment and ensures documentation and coding are consistent and supported across the record, including visit notes, certificates of terminal illness, face-to-face documentation, and referrals. It monitors ICD-10 coding accuracy, determination of terminal illness relatedness, and selection of applicable comorbidities. The role also oversees quarterly medical record reviews, analyzes findings, identifies improvement areas, abstracts information, and produces QAPI reports using tools that measure and analyze compliance. Findings are reported to management. The Manager is responsible for Hospice Quality Reporting Program (HQRP) outcome data and uses findings to support quality improvement efforts. The role identifies, develops, and monitors Performance Improvement Plans (PIPs) based on outcome analysis, industry changes, and agency opportunities and needs.
Requirements
- Current license to practice as a Registered Nurse in the State of Connecticut.
- Baccalaureate degree in nursing.
- At least ten years of clinical nursing experience, including at least five years in a hospice agency.
- Knowledge of quality assurance and performance improvement activities.
- Knowledge of Medicare Hospice Conditions of Participation and State of Connecticut regulations.
Nice To Haves
- Master's degree in nursing.
Responsibilities
- Develop, implement, and maintain an ongoing, data-driven clinical quality assessment and performance improvement program focused on clinical outcomes, patient and family care, and patient health and safety.
- Review and oversee clinical documentation for quality of care and compliance with Conditions of Participation, state regulations and licensing requirements, and local coverage determinations.
- Assist with QAPI activities, potentially including the 120-Day Report, Quarterly Record Review, and initiatives for inpatient and home hospice settings.
- Oversee the timeliness and completeness of Plans of Care/Treatment and ensure documentation and coding are consistent and supported across the record.
- Monitor ICD-10 coding accuracy, determination of terminal illness relatedness, and selection of applicable comorbidities.
- Oversee quarterly medical record reviews, analyze findings, and identify areas for improvement.
- Abstract information and produce QAPI reports using tools to measure and analyze compliance; report findings to management.
- Manage Hospice Quality Reporting Program outcome data and use findings for quality improvement efforts.
- Identify, develop, and monitor Performance Improvement Plans based on outcome analysis, industry changes, and agency opportunities and needs.
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What This Job Offers
Job Type
Full-time
Career Level
Manager
