Hospice Compliance, Quality, and Education Program Manager

Building Location:

Support Services Building

Department:

2854010 HOSPICE - SMMC

Job Description:

Collaborates with leadership team assuring compliance with relevant federal, state, local, and accrediting body standards and requirements; performing chart audits, QAPI projects, and providing education as needed including responsibilities in the electronic medical record system. This person is responsible for developing audit reports, communicating findings and making recommendations for process improvements. They take part in the assessment, development and evaluation of education and training activities that enhance the performance, professional development, and continuing competence of hospice and palliative care clinicians as well as participating in the development and execution of innovative education programs and initiatives that advance the mission and vision of Essentia Health Home Hospice and Palliative care. Collaborates with leadership team.

Education Qualifications:

Key Responsibilities:

• Assists in development of department wide QAPI program by leading staff to identify their concerns with care issues and to identify areas for improvement. The QAPI program includes but is not limited to clinical outcomes, internal process measures and family satisfaction. Monitors key metrics for the department
• Independently create data and tools to capture changes in quality processes and to utilize critical judgment to prioritize action steps for quality improvement
• Provides reports on a regular basis, and as directed or requested, to keep the Management Team and Governing Body informed of the operation and progress of audit efforts
• Conducts regular audits of patient records, clinical systems and documentation to assure compliance with policies and procedures and regulatory bodies
• Ensures proper reporting of violations or potential violations to necessary management staff
• Responds to alleged violations of rules, regulations, policies, procedures, and Standards of Conduct by evaluating or recommending the initiation of investigative procedures and develop and oversees a system for uniform handling of such violations
• Monitors, and as necessary, coordinates compliance activities to remain abreast of the status of all compliance activities and to identify trends.
• Identifies potential areas of compliance vulnerability and risk; develops/implements corrective action plans for resolution of problematic issues and provides general guidance on how to avoid or deal with similar situations in the future
• Establishes and provides educational standards in alignment with governing body guidelines
• Institutes and maintains an effective compliance, quality and education program for the department, including promoting (a) understanding of new and existing compliance issues and related policies and procedures (b) heightened awareness of Standards of Practice (c) Monitoring quality measures and trends and (d) ensuring ongoing education of department staff
• Assists with the educational onboarding of new department staff
• Maintains up-to-date educational resources for new staff and current staff

Educational Requirements:

• Minimum 2-year RN degree, Bachelor’s RN degree preferred

Required Qualifications:

• Professional Licensure as a Registered Nurse in either Minnesota or Wisconsin and the ability to obtain either licensure within 3 months of hire
• 2-5 years of related experience in any of the following: process improvement, nursing practice council, staff education and development, nursing, quality, and compliance

Preferred Qualifications:

• Hospice Experience 
• Proficiency in Microsoft Office (Excel, SharePoint, Word, Power Point)

Licensure/Certification Qualifications:

FTE:

1

Possible Remote/Hybrid Option:

Shift Rotation:

Day Rotation (United States of America)

Shift Start Time:

Shift End Time:

Weekends:

Holidays:

No

Call Obligation:

No

Union:

Union Posting Deadline:

Compensation Range:

$76,315.20 - $114,483.20

Employee Benefits at Essentia Health:

At Essentia Health, we’re committed to supporting your well-being, growth, and work-life balance. Our comprehensi