Hospice Quality Assurance Manager

Job Description

Job Description

Benefits:

• 401(k)
• Competitive salary
• Opportunity for advancement
• Paid time off

The QA Manager oversees the quality of charting and QUAPI program by managing chart auditsmaking sure care is safe, effective, patient-centered and compliant with regulations.

Key Roles & Responsibilities

1. QAPI Program Oversight

• Manage and implement the hospice QAPI plan
• Identify areas for improvement using data (falls, infections, hospitalizations, etc.)
• Lead performance improvement projects (PIPs)
• Track and report outcomes to leadership

2. Regulatory Compliance

• Ensure compliance with:
  • Medicare Conditions of Participation
  • State regulations
• Prepare for surveys (CMS and state)
• Conduct mock surveys and audits
• Maintain readiness at all times (survey-ready culture)

3. Clinical Chart Audits

• Review patient charts for:
  • Proper documentation
  • Eligibility (LCD guidelines)
  • Timeliness (admissions, recertifications, visits)
• Identify trends in documentation deficiencies
• Provide feedback to clinical staff

4. Education & Staff Training

• Educate staff on:
  • Documentation standards
  • Regulatory updates
  • Quality initiatives
• Conduct in-services and competency training
• Collaborate with clinical leadership (DPCS)

5. Incident & Risk Management

• Oversee reporting and investigation of:
  • Falls
  • Medication errors
  • Patient/family complaints
• Perform root cause analysis (RCA)
• Implement corrective action plans

6. Performance Metrics & Data Tracking

• Monitor key hospice quality indicators:
  • CAHPS Hospice Survey scores
  • Hospitalizations/revocations
  • Pain and symptom management effectiveness
• Analyze trends and present reports to leadership/IDT

7. Policy & Procedure Management

• Develop and update hospice policies/procedures
• Ensure policies align with current regulations
• Assist departments in implementing policies correctly

8. Interdisciplinary Team (IDT) Collaboration

• Attend IDT meetings to ensure:
  • Compliance with care planning
  • Documentation supports hospice eligibility
• Support clinicians with quality improvement strategies

9. Survey & Audit Response

• Lead response to:
  • State/CMS survey findings
  • ADRs (Additional Documentation Requests)
• Create Plans of Correction (POCs)
• Ensure follow-through on deficiencies

Key Skills Needed

• Strong knowledge of hospice regulations (CMS, state)
• Clinical background (LVN or RN)
• Detail-oriented with strong auditing skills
• Data analysis and reporting ability
• Leadership and communication skills