Job Summary

The Quality Manager (QM) is responsible for accurate and timely completion of key quality functions across all agency service lines. Primary duties include: oversight and implementation of the Quality Assessment Performance Improvement (QAPI) program; Infection Control and Employee Health Program; coordination and execution of all clinical audits. Additional responsibilities include supporting Process Improvement Projects (PIPs) and administration of Unusual Occurrence Report (UOR) system.

Essential Responsibilities

Quality Assessment/Performance Improvement

• Prepares and conducts quarterly QAPI meeting
• Ensures all routine quality data is collected and presented in a timely fashion
• Coordinates and ensures completion of clinical audits and quality surveillance
• Assists in response to audit requests, e.g., ADRs, SMRC, MAC, TPE
• Provides coaching/training for leaders and staff when areas are identified
• Manages Unusual Occurrence Report (UOR) system
• Serve as a member of the Project Advisory Council (PAC)
• Collaborates with Chief Clinical Officer in development and implementation of key quality-related activities across the organization, including:
  • Quality and Performance Improvement policies and procedures
  • Oversight of QAPI program and annual QAPI plan
  • Implementation of appropriate quality monitors

Infection Control and Employee Health Coordination

• Develops and maintains all aspects of HSCC Infection Control Program
• Maintains policies, procedures and forms related to Infection Control and Employee Health
• Provides oversight of non-clinical staff assisting with Infection Control operations (e.g., contact tracing, annual employee clinic
• Develops training & in-service materials
• Oversight of Fit Testing program (Determination of staff to be tested, communication to staff/managers about Fit Testing, review of Fit results, mask ordering and stocking (in conjunction with operations), and follow up as needed)
• TB testing oversight (performs TB clinics and ad hoc screenings)
• Annual flu vaccine messaging, oversite and tracking
• Employee infection control tracking

Accreditation Coordination

• Participates in IDG Policy Review and SOP Review Committee
• Coordinates with accrediting body as directed by Chief Compliance Officer
• Prepares PER submission in collaboration with Chief Compliance Officer

Leadership:

• Articulate and support HSCC mission, vision and values through all Quality initiatives, strategy and transactions
• Create Quality/Infection Control trainings that support a culture of ownership and that align employee work and performance within that desired culture

Secondary Responsibilities:

• Backup for Director of Clinical Education
  • Orientation for new staff
• Performs other related job duties as assigned by Supervisor

Compliance

• Ensures all HIPAA Privacy and Security Regulations, Medicare Conditions of Participation, and all other regulatory/compliance requirements are understood and followed

Requirements

Education/Experience

• Degree in Nursing from an accredited college, Preference to BSN
• Hospice, Quality Assessment/Utilization Review, and/or Computer Charting/Auditing experience required.
• Netsmart experience preferred
• Facility (SNF/RCFE) experience preferred.

Skills Required

• State & Federal hospice regulatory knowledge
• Systems development
• Organizational skills
• Technological skills including Excel, PowerPoint
• Communication & teaching skills

Certifications, Licenses, Registrations

• Require current California RN license, Preference to BSN
• Pass OIG/GSA review and all required background checks

Physical Demands

• Strength to lift and carry materials weighing up to 10 pounds
• Vision to read printed materials and a computer screen
• Hearing and speech to communicate in person and over the telephone

Work Environment/Environmental Condition

• Must possess mobility to work in a standard office setting and to use standard office equipment, including a computer