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1225 W State Street, Olean, NY
Reporting to the Chief Executive Officer, is responsible for, but not limited to, developing,implementing and maintaining an effective, ongoing, comprehensive and data driven quality assessment and performance improvement (QAPI) program for the organization and its related entities. Provides direct clinical oversight of nursing services and medical director relationship to home care, hospice, and palliative care programs, coordinating service development and quality goals. Provides clinic-based collaborative nursing oversight for managed care services. Assures compliance with staff education requirements and NYS approved training curriculums. Prepares and recommends the overall Quality Improvement (QI)and QAPI plan documents for adoption/revision on a timely basis; insures ongoing policy development and annual review as required; maintain a focus on compliance with regulatory requirements pertaining to quality care delivery as well as in response to identified needs; promotes opportunities for input from persons served and other constituencies with regard to quality improvement issues; provides comprehensive and effective response to any identified deficiencies; provides supervisory oversight for QI staff in conducting required clinical record reviews and with all QI activities. Serves as an integral member of the senior management team and as the organization’s Compliance Officer, as well as key staff leadership for the QI committee(s) of the governing authority and internal risk management committee.
1. Prepares the QI and QAPI program plans,revising and updating as needed, in accordance with regulatory requirements and identified goals of the organization.
2. Maintains quality care standards for delivery of nursing services in compliance with existing policies, regulatory requirements, and contractual parameters, including case management responsibilities, in collaboration with nursing and medical staff.
3. Provides oversight and ensures completion of scheduled clinical record reviews, as well as unscheduled monitoring for assessment of the quality and safety of services provided to patients/participants.
4. Develops, revises, and insures required review of policy and procedure pertaining to care and related services provided by the organization, insuring timely updates to manuals.
5. Promotes and facilitates opportunities for electronic data management and access.
6. Supervises the implementation of direct and contracted patient/participant survey methods to obtain quality improvement data.
7. Promotes high standards and oversight of the organization’s training and equivalency programs, orientation procedures, and in the quality of care delivered by employees.
8. Prepares and reviews reports, providing presentation of data in effective formats.
9. Maintains agency quality improvement records in accordance with regulatory requirements.
10. Provides leadership to the QI and risk management committees’ processes.
11. Implements performance improvement initiatives and focus studies as planned, directed,
and/or identified to enhance assessment of services and the potential for improvement in patient/participant care and safety.
12. Ensures completion of QI data collection, entry, and reports required for regulatory compliance.
13. Retains the title and associated responsibility of Compliance Officer for assigned organization (see related job description).
14 Provides leadership for nursing management to assist in augmenting clinical effectiveness, the achievement of service goals, and the consistent application of protocols.
15. Supervises,trains, orients and evaluates assigned staff; engages staff effectively.
16. Participates in providing agency inservice and orientation programs as applicable and as may be assigned.
17. Participates as the QI and senior nursing/clinical representative to all survey processes initiated by regulatory authorities, proving appropriate verbal and written responses to identified issues.
18. Oversees the coordination of the organization’s emergency and disaster preparedness plan,conducting intermittent drills to insure adequacy and readiness.
19. Oversees and/or conducts quality improvement activities, external to agency functions as may be required.
20. Ensures all necessary complaint documentation and follow-up to issues and identified problems occur within the time frames identified by agency/operational policy/procedure.
21. Communicateseffectively with the senior management team as a member.
22. Adheres to and reflects organizational valuesin daily work.
23. Serveson agency committees as may be assigned.
24. Maintains a professional obligation to report wrongdoing/violation of agency policies, applicable federal, state and local laws, and rules and regulations pertaining to agency operations, to immediate supervisor.
25. Completes all mandatory inservice education programs, participates in appropriate education and training programs appropriate for the position, and completes other inservice hours that are minimally required.
The above examples of work may not be a complete statement of all assignments that may be inherent to the position. Other duties may also be assigned as deemed necessary and appropriate by the Administrator/CEO.
1. Bachelor’s Degree in Nursing with current NYS nursing license and registration.*
2. Four years nursing experience,preferably in hospice or home care, with at least 2 years of the minimum required experience involved with the management and/or delivery of quality improvement programs, studies, or initiatives.
3. Knowledge of quality improvement program design, execution, and reporting. Knowledge of federal and state hospice/home care/ PACE regulations preferred.
4. Demonstrated supervisory and organization skills.
5. Computer literacy and knowledge of word processing and data base programs; Microsoft office experience and literacy preferred; experience or demonstrated ability to work with electronic medical records.
6. Effective verbal and written communication skills.
7. Acceptable driver’s license and automobile available for use with current insurance.
Job Type: Full-time