Performance Improvement Specialist

About the role

The Performance Improvement Specialist supports and facilitates quality assessment and performance improvement (QAPI) activities for the local hospice branch. The QAPI Program involves data collection, analysis, and collaborative development of performance improvement initiatives.

Responsibilities

• Data collection and analysis of data associated with HQRP components, including CAHPS, claims-based measures, Hospice Item Set, and any future measures.
• Data collection, tracking, and benchmarking HQRP scores against competitors through Care Compare.
• Data collection, analysis, and reporting for the optional CAHPS analysis process.
• Identify negative comments/responses from CAHPS surveys and initiate service comments as necessary.
• Analyze and report data from the QAPI dashboard.
• Maintain and analyze data for infection control reporting and incident reporting.
• Facilitate Root Cause Analysis meetings and ensure required documents are completed.
• Analyze and trend Unaccrued Revenue using provided reports and report findings to program management.
• Obtain and report training completion reports for Hospice Aide in-service hours, Annual Update HIPAA/OSHA, and Physician satisfaction surveys.
• Monitor and report on revocation and discharge monitoring data.
• Collect and analyze quality indicator data/key performance indicators and collaborate with senior management to identify priorities for improvement and develop initiatives.
• Prepare and submit monthly Quality Update Reports (QUR) to regional and senior management.
• Prepare and co-facilitate QAPI IDG Committee Meeting minutes and documents.
• Complete and submit Annual Reports for the QAPI Program.
• Facilitate Performance Improvement Projects and maintain documentation of initiatives.
• Identify program needs based on data analysis and recommend training to address these needs.
• Report to senior management on compliance with required trainings including orientation and legally-mandated in-services.
• Act as the program liaison to central support and submit quarterly QAPI IDG and annual report documents including policy recommendations via the Governing Body Report.
• Provide field perspective and participate in the development of company-wide materials regarding quality initiatives.
• Collaborate with the PCA for external audits and records requests.
• Participate in pilot projects related to QAPI initiatives as requested.
• Oversight of the Performance Improvement Specialist (PIS) Assistant, including delegation of approved tasks and mentorship for delegated tasks as needed.

Requirements

• Ability to work independently and prioritize activities to meet deadlines.
• Detail-oriented with the ability to analyze quality data and identify trends.
• Strong oral and written communication, presentation, and facilitation skills.
• Strong computer and technology skills (MS Excel, MS Word, MS PowerPoint, MS Teams, MS Outlook).
• Strong organizational skills with the ability to multi-task.
• Ability to motivate and lead change management and performance improvement.
• Ability to travel as required.
• Licensed (as required) health care professional or non-clinician with quality background (preferred).
• Certified Professional in Health Care Quality (preferred).
• Knowledge of Medicare/Medicaid regulations, state licensure laws, and the requirements of any other applicable regulatory/accrediting body.
• Experience with data collection, measurement tools, and data analysis.
• Experience in a quality assurance/improvement role with an understanding of performance improvement concepts (preferred).