Hospice of Santa Cruz County
  • Quality & Education
  • Scotts Valley, CA, USA
  • 100000.00-150000.00 per year
  • Salary
  • Full Time

For Full Time Employees: employer pays 100% of employee premiums for medical, dental, vision, life and long-term disability

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


  • 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


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



  • 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
Hospice of Santa Cruz County
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