You Make Us Grow. You Make Us Sharp.

Hours:

Shift Start Time:

8 AM

Shift End Time:

4 PM

AWS Hours Requirement:

8/40 - 8 Hour Shift

Additional Shift Information:

Weekend Requirements:

Not Specified

On-Call Required:

No

Hourly Pay Range (Minimum - Midpoint - Maximum):

$75.460 - $97.370 - $119.280

The stated pay scale reflects the range that Sharp reasonably expects to pay for this position.  The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

What You Will Do
The Supervisor of Quality and Regulatory Compliance for Hospice supports and oversees the hospice team in conjunction with the Hospice leaders to deliver exceptional end-of-life care. This role is responsible for ensuring operations meet all regulatory requirements to deliver the highest standard of patient care. This Supervisor provides support to the four SharpCare Hospice Homes, home hospice patients, and hospital inpatient hospice patients, in addition to home health patients and inpatient hospice patients. This position is responsible for the Hospice Quality Reporting Program (HQRP), identifying areas for improvement, and being a change agent.

Required Qualifications

• Bachelor's Degree
• 5 Years experience in hospice and with hospice regulations.
• 2 Years Leadership experience.
• California Registered Nurse (RN) - CA Board of Registered Nursing -REQUIRED

Preferred Qualifications

• Experience in quality and performance improvement (PI) in the healthcare environment.
• Certified Professional in Healthcare Quality (CPHQ) - National Association for Healthcare Quality -PREFERRED
• HPCC Certified Hospice and Palliative Nurse (CHPN) - Hospice and Palliative Credentialing Center -PREFERRED
• HPCC Certified Hospice and Palliative Care Administrator (CHPCA) - Hospice and Palliative Credentialing Center -PREFERRED

Other Qualification Requirements

• Hospice Manager Certificate Program - Preferred

Essential Functions

• Performance Improvement
  Works collaboratively with leadership to set and achieve agency, department, and staff goals.
  Establish and maintains collegial relations and collaborates with leadership, risk management, and clinical/ancillary/support service staff in cross-functional process improvement, collaborative teamwork, open communication, and problem solving.
  Utilizes independent judgment, training and clinical experience to recognize variances in quality/patient safety and opportunities for performance improvement. Participates in implementation of practices and procedures to improve quality of patient care. Manage efforts of performance improvement to enhance department and organizational effectiveness and/or corrective action to facilitate performance improvement.
  Effectively uses ongoing monitoring techniques including corrective action process, criteria development, and statistical analysis to sustain improved processes.
  Identifies statistical trends in data through utilization of independent judgment, training and clinical experience in analysis of case reviews, system reviews, and/or of clinical data.
  Perform regularly scheduled audits, analyze regulatory changes, and recommend improvements in conjunction with Hospice CMO, Chief Operating Officer, along with hospice leaders.
  Analyzes results of external surveys (CAHPS Hospice Survey and EGSS) and processes each survey according to assessed needs.
  Provides education and technical support specifically for the development, implementation, and maintenance of PI activities.
• Leadership
  Manage staffing, scheduling, and recruitment of hospice personnel to maintain optimal team performance.
  Oversee the day-to-day operations and staff oversight for all four Sharp hospice home locations, in addition to home hospice patients, and inpatient hospice patients.
  Monitors performance and provides timely performance reviews. Provides ongoing coaching, counseling, guidance, and, as needed, corrective action.
  Leads and manages work teams based on organization goals and performance improvement needs.
  Manages follow-up with teams/work groups to ensure projects are completed and ongoing data collection is managed and documented as needed.
  Facilitates multi-disciplinary PI teams to address and resolve identified quality issues and improve performance.
  Facilitate ongoing education and training for nursing staff to promote professional growth and adherence to clinical standards.
  Provides education to clinicians to promote/improve patient safety and quality.
• Quality and Patient Care
  Makes recommendations to the multidisciplinary team in development of the patient's plan of care. Reviews written plan of care (IPOC) documented by the RNs.
  Collaborate with interdisciplinary teams to coordinate comprehensive care for patients and their families, including emotional and spiritual support.
  Leads and oversees the internal quality auditor’s regular reviews of patient hospice encounters to ensure documentation meets the standards to align with the billing codes submitted for reimbursement for the four levels of hospice care (routine home care, continuous home care, inpatient respite care, and general inpatient care).
  Conduct regular assessments of patient care quality and outcomes, utilizing data to enhance service delivery.
  Serve as a liaison between families and healthcare providers, addressing concerns and ensuring clear communication regarding care plans.
• Regulatory Compliance
  Maintain regulatory compliance with licensure, Medicare Conditions of Participation, The Joint Commission, state and federal requirements, and other accreditation standards.
  Participate in the review and revision of policies and procedures to meet regulatory requirements and department needs.
  Participate in the development of and coordinate the implementation of educational programs, including orientation, to address staff members needs and to meet regulatory requirements.
  Prepare reports for the Quality/Safety Council, as assigned.
  Ensure compliance with Title 22 of the California Code of Regulations regarding hospice care for terminally ill clients, to include: facility hospice care waivers, training for staff, and ensuring the plan of care is current and meets the client's needs.
  Assist with managing hospice licensure. Ensures licensure are current and renews per regulatory agency’s protocol (i.e, HS200 licensure and certification applications).
  Lead the responsibilities in compiling and verifying documentation for new facility applications, licensure changes, and renewals for hospice operations.
  Manages the CDPH reporting obligations in the event of a reportable privacy breach or an event that requires timely reporting to CDPH per the State regulations.
  Collaborates with facility (Grossmont) regulatory leadership to regularly assess and address operations for increased regulatory compliance in addition to best quality practices and standards.
  Maintains knowledge of CMS hospice billing and guidelines including sequential billing, record keeping (Form CMS-1450), injectable/non-injectable prescriptions, etc.

Knowledge, Skills, and Abilities

• Intermediate computer skills required including working knowledge of PowerPoint, spreadsheets, statistics, and clinical information systems.
• Current knowledge of Joint Commission, State, and Federal regulatory agency requirements, standards and regulations.
• Excellent interpersonal and communication skills, with a compassionate approach to patient care, the ability to get along with others and work cooperatively in a team environment to establish, build and maintain positive work relationships and to ensure deadlines, goals, and objectives are met.
• In depth expertise of Title 22 of the California Code of Regulations regarding hospice care for terminally ill clients.
• In depth understanding of all common hospice billing codes requirements, such as the Q-codes to indicate the location of care (e.g., Q5003 for a nursing facility, Q5004 for a skilled nursing facility) in addition to use of modifiers such as, GV (services related to hospice care) and GW (services unrelated to hospice care) are used to report claims accurately.
• In depth experience with understanding a patient population that meets the CMS criteria for hospice care.
• Knowledge of Quality Assessment Performance Improvement (QAPI).

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class

Certified Professional in Healthcare Quality (CPHQ) - National Association for Healthcare Quality; HPCC Certified Hospice and Palliative Nurse (CHPN) - Hospice and Palliative Credentialing Center; HPCC Certified Hospice and Palliative Care Administrator (CHPCA) - Hospice and Palliative Credentialing Center; California Registered Nurse (RN) - CA Board of Registered Nursing; Bachelor's Degree