HOS Continuous Quality Improvement Nurse

Description:

Position Summary

The Continuous Quality Improvement (CQI) Nurse monitors, analyzes, and improves clinical quality and regulatory compliance across all hospice locations. This role uses QAPIplus analytics, documentation audits, and CMS quality indicators to identify improvement opportunities, implement corrective actions, and support survey readiness.

QAPI & Compliance Oversight

• Monitors QAPIplus dashboards daily for clinical and documentation indicators. • Tracks CTI/F2F, IDT compliance, POC updates, orders, and symptom management. • Conducts documentation audits and manages corrective action plans. • Leads performance improvement projects (PIPs).

Clinical Quality Monitoring

• Identifies quality-of-care concerns including pain delays, symptom escalation, and safety events. • Completes root cause analyses (RCAs) and leads follow-up actions. • Monitors triage response times and clinical interventions.

Documentation Audit & Review

• Performs monthly documentation audits for CTIs, recerts, orders, visit frequency, and interdisciplinary notes. • Ensures survey readiness for state, federal, and accreditation bodies.

Education, Coaching & Staff Development

• Provides targeted coaching and documentation training based on QAPIplus findings. • Supports onboarding with QAPI and compliance standards. • Works with educators and PCMs to standardize best practices.

Data Reporting & Analytics

• Generates monthly QAPI reports with compliance scoring and trend analysis. • Produces branch performance scorecards and dashboards. • Prepares governing body and executive summaries.

Interdisciplinary Collaboration

• Collaborates with PCMs, medical directors, triage nurses, and leadership. • Participates in IDT meetings to address documentation or quality issues.

Policy, Procedure & Process Improvement

• Updates and reinforces quality-related policies. • Supports standardization across all branches and disciplines.

Requirements:

Qualifications

• Active RN license in good standing.
• Minimum 2–3 years hospice experience required.
• Strong working knowledge of CMS Hospice CoPs.
• Experience with QAPI, compliance, or quality preferred.
• Proficient in QAPIplus, Consolo, WellSky, or similar platforms.

Core Competencies

• Regulatory compliance knowledge
• Clinical quality analysis
• Documentation accuracy
• Coaching & education
• Accountability & follow-through
• Data interpretation & reporting