Director of Quality and Compliance

Job Summary

The Director of Quality and Compliance is accountable for the monitoring, implementation and evaluation of processes and programs to meet all regulatory, accreditation and standards of practice for the agency. Assures compliance with State and Federal regulations and standards for licensing and certification. Works collaboratively with leadership team to implement new policies and evaluate existing policies as required or needed to assure compliance with all regulatory requirements.

Grace Culture

Successful employees will demonstrate these key values:

• Excellence: Anticipating needs and delivering the best care by going above and beyond expectations.
• Kindness: We distinguish ourselves by being friendly, considerate and generous as we care for patients, families and each other.
• Team: Respectfully working together to achieve the best end of life experience for our patients and families; promoting a positive work experience

Job Duties

- Provide leadership and supervision for Quality Assurance Specialist, Education Specialist and Clinical Administrative Staff.
- Maintains current knowledge related to Medicare Conditions of Participation and Minnesota Statutes to ensure that the agency is compliant with state and federal regulations, HIPAA compliance
- Monitors the measurement, implementation, evaluation of the following quality measures, including but not limited to; Hospice Compare, HPCAHPS, CASPER, HIS and PEPPER
- Responsible for infection control/surveillance program-collection, analysis and reporting for the agency’s infection control and adverse event reporting
- Coordinates and leads QAPI meetings on an at least quarterly basis, publishes agendas and minutes and maintains QAPI records
- Provides direction and coordination of quality improvement activities utilizing input from the team, current data trends and other methodologies
- Compiles, trends and reports quality data in the following areas; patient care, safety risk management, infection control, patient and family satisfaction in a monthly data dashboard
- Provide leadership guidance and support for new program development/opportunities.
- Provides Quality and Compliance reports to the board of directors.
- Assist with budgeting and staffing plans utilizing team input
- Supervisor on-call responsibilities
- Responsible for ensuring policies and procedures reflect local, state and federal standards and makes recommendations for policy changes to management and the governing board.
- Acts as a resource to management and staff regarding standards, policies and regulations and provides training to leadership and staff as needed in these areas.

Qualifications

• Previous hospice experience
• Graduate of accredited school of nursing for Registered Nurse; registered and licensed in the State of Minnesota
• Excellent verbal and written communication skills
• Strong organization skills-able to manage projects from initiation to implementation.
• Strong leadership skills-provide clear leadership direction on quality projects, education to team on quality, compliance initiatives.
• Competency with Microsoft Office programs, EMRs, CMS programs, other relative databases (example pharmacy) and database management and analysis.
• Expert in current regulatory knowledge; Federal, State and Medicare COP’s

Benefits Include

• Competitive salary
• Medical insurance
• Dental insurance
• Vision insurance
• Long/short-term disability
• Basic life/AD&D
• Supplemental Life/AD&D
• Dependent Life/AD&D
• Paid vacation and sick days and holidays
• Flexible spending accounts for healthcare and dependent care reimbursement