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Jordan Hospital RN Quality Supervisor in Plymouth, Massachusetts

POSITION SUMMARY: In accordance with Agency policy, supervises staff, establishes, maintains, and evaluates nursing standards of care and service for the Agency. Responsible for assisting with coordination of the QAPI program. Responsible for gathering all required information and chart audits for ADR’s and other audits from Regulatory bodies, Insurance companies, etc. Monitors and maintains compliance with regulatory changes that affect coding and reimbursement Manages projects and works with non-clinical and clinical staff to ensure successful outcomes. Ensures compliance with Joint Commission Standards.


  • Supervises nursing staff and nursing practice consistent with Agency and professional standards and policies. Ensures the orientation of new staff and, in collaboration with the Hospice Director, counsels and evaluates staff. Acts as a resource/mentor for patient care management for staff.

  • Identifies education needs and participates in educational programs

  • Participates in developing and maintaining staff competency program

  • Communicates regularly with nursing staff, peers and immediate supervisor

  • Works with Intake Team to ensure admission paperwork is correct and ready for Admitting RN and MSW. Establishes and follows an Admission Checklist to ensure all paperwork is signed and received.

  • Ensures submission and tracking of all CTI’s, MD orders and other time sensitive documents.

  • Provides backup to Business Manager for insurance verifications, respite contracts, transfer paperwork and demographic data in Business Manager.

  • With Hospice Clinical Director and QAPI Supervisor, establishes the Annual Comprehensive QAPI Evaluation and Plan for the upcoming year.

  • Monitor and Evaluate QA Measures which include, but are not limited to, Patient Fall, Patient Infections, Adverse Events, Hospice Benchmark Data.

  • Initiates the FMEA focusing on high volume, high risk processes of the agency.

  • Leads the Infection Control Program, coordinates with the hospital and educates staff and patients/families.

  • Develops and assesses the Hazard Vulnerability Analysis with the Clinical Director.

  • Maintains/reviews the Emergency Response Plan with the QAPI Supervisor.

  • Review/evaluate QA data provided by Deyta, FEHS, FEBS, Pepper and CMS as well as EMR chart audits

  • Initiates and collaborates with staff on various Performance Improvement Projects

  • Implements and Coordinates CMS Quality Reporting Program

  • Audits charts periodically to assess for completeness and compliance with all Regulations and various clinical outcome measures.

  • Promotes quality achievement and performance improvement throughout the organization.

  • Ensures adherence to federal, state, and Agency regulations and policies.

  • Participates in the Massachusetts Federation’s Hospice QAPI organization and collaborates with other MA Hospices in various projects.

  • Supervises the regulatory compliance of the EMR and educates staff in an ongoing manner with all updates and changes.

  • Ensures/supervises that documentation in all areas is correct, complete and compliant.

  • Collaborates with IT department in customizing health care technical systems and programs.

  • Collaborates with IT department to implement upgrades to the EMR and educates staff on all aspects.

  • Creates and prepares a variety of relevant reports and educates staff regarding documentation to facilitate data collection.

  • Other responsibilities as directed.

  • Assumes on-call responsibility as needed

  • Provides direct patient care, when necessary

  • Ensures/supervises that documentation in all areas is correct, complete and compliant.

    Education/Experience Required:

  • Current Massachusetts RN license

  • BSN

  • Minimum three years management experience in hospice, home care or health related setting

  • Demonstrated experience in effective supervision and communication.

  • Extensive knowledge of Quality Management, Staff Education Training in the use of Coding and Reimbursement Software and external reporting sites.

    Knowledge and Abilities:

  • Comprehensive knowledge of documentation compliance

  • Excellent written, oral and presentation skills

  • Demonstrated leadership and customer service approach in hospice, homecare or related setting

  • Working knowledge of hospice EMR, Microsoft Office, including Word and Excel

  • Excellent verbal and written skills.

  • Working knowledge of CMS regulations pertaining to Hospice/Home Care

  • Knowledge of Agency philosophies, policies and programs.

  • Extensive knowledge of Quality Management, Staff Education

  • Exhibits excellent problem solving skills and critical thinking.

  • Current knowledge of relevant local, state and federal regulations governing hospice/home care.

  • Thorough knowledge of methodologies of quality assurance and standards

  • Excellent numerical skills and understanding of data analysis/statistical methods; great attention to detail and outcome based approach.

  • Excellent organizational and leadership abilities.

  • Ability to manage projects and work as a liaison between clinical and non-clinical areas to reach successful outcomes.