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Summary Description:

Coordinates Baystate Hospice to CMS, and Hospice Quality Management and Performance Improvement programs. Assists in coordinating MA Department of Public Health compliance activities for quality management, performance improvement, and patient safety.

Adhere to system and department compliance policies and any applicable laws and regulations.

Schedule:

Monday thru Friday, 8am - 4:30pm

Location:

30 Capital Dr West Springfield, MA

Job Responsibilities:

**1)** Functions as Quality Assurance/Performance Improvement (QAPI) Coordinator for Home Care and Hospice project teams. Serves as resource/liaison/educator to clinical and non-clinical staff members regarding performance improvement processes.

Ensures that systems and/or process issues identified during performance improvement activities are referred to the appropriate department(s) or teams for resolution.

Utilizes PDSA cycle, lean methodologies, and other quality improvement tools as appropriate in performance improvement activities.

Ensures that documentation of all QAPI activities is complete, accurate, easily retrievable, and current.

Ensures appropriate QAPI initiative documentation and issue resolution to maintain compliance with Hospice CMS Conditions of Participation and any other federal and state regulations.

**2)** Collects data from a variety of sources, including the EMR and HIS outcomes to support identified quality of care and patient safety measures.

Manages, implements, and evaluates Quality Assurance/Performance Improvement (QAPI) activities, including collecting and analyzing data and preparing formal reports for presentation.

Manages the coordination of data collection and reporting of performance improvement (PI) data as needed to meet the requirements of external regulatory agencies and third-party payers.

**3)** Tracks risk events, including infections and patient harm. Uses data to create QAPI initiatives to prevent further occurrences.

**4)** Reviews and submits HIS data within the regulatory timeframes, reviews documented diagnoses, and ensures diagnoses and clinical documentation are consistent.

**5)** Understands and is able to teach Hospice Conditions of Participation to both clinical and non-clinical staff.

**6)** Works with the Medical Records and Finance Departments to ensure clinical documentation contains all elements necessary for billing claims.

**7)** Responds to Additional Requests for Documentation (ADRs) from CMS and other third-party payers with clear, accurate written documentation.

**8)** Maintains a collaborative working relationship with all staff and external contacts.

**9)** Contributes to the day-to-day functioning of the Quality department. Assists with special projects as assigned.

**10)** Assumes responsibility for own professional growth and development, including attending appropriate educational programs and maintaining clinical knowledge relevant to performance improvement responsibilities.

Preferred Experience:

_Minimum 2 years of Hospice Quality/Performance Improvement experience_

ICD-10 Certification

Skills/Competencies:

Ability to organize and prioritize workload to meet deadlines.

Ability to facilitate performance improvement process.

Ability to manage multiple competing priorities.

Ability to collaborate with both clinical and nonclinical staff members.

Strong written and oral communication skills.

Must possess excellent interpersonal skills.

Ability to organize and prioritize workload to meet deadlines.

Ability to facilitate performance improvement process.

Ability to manage multiple competing priorities.

Ability to collaborate with both clinical and nonclinical staff members.

Strong written and oral communication skills.

Must possess excellent interpersonal skills.

Excellent computer skills, including word processing and database software.

You Belong At Baystate

At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. It makes us not just an organization, but also a community where you belong. It is how we advance the care and enhance the lives of all people.

DIVERSE TEAMS. DIVERSE PATIENTS. DIVERSE LOCATIONS.

Education:

Associates of Science (Required), Bachelor of Science

Certifications:

Registered Nurse - State of MassachusettsState of Massachusetts

Equal Employment Opportunity Employer

Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.