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 audits—making 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