QAPI (Quality Assurance and Performance Improvement) and Compliance Manager

CareFirstNY is a non-profit organization that provides hospice services, grief support and community counseling to residents of Chemung, Schuyler, and Steuben counties in New York State.

We’re seeking a compassionate and dedicated QAPI (Quality Assurance and Performance Improvement) and Compliance Manager to join our team!

Benefits include:

• Health Insurance (3 options)
• Dental Insurance
• Vision Insurance
• Employer-Paid Life Insurance
• Voluntary Life and AD&D
• 401(k) with Employer Match
• Employer-Paid Long-Term Disability
• Flexible & Dependent Care Spending Account
• Health Savings Account
• Generous Paid Time Off
• 10 Paid Holidays and 1 Float Holiday
• Long-Term Illness Bank
• Employee Assistance Program
• Tuition Reimbursement Program
• Flexible Schedule
• And MORE!

Summary:

The QAPI (Quality Assurance and Performance Improvement) and Compliance Manager is responsible for driving excellence in care delivery, maintaining regulatory compliance, and fostering continuous performance improvement. This role oversees the organization’s QAPI program, shares in the supervision of the interdisciplinary team of clinical staff, ensures full adherence to all applicable regulations, and cultivates a culture rooted in quality and accountability. Through these efforts, the QAPI and Compliance Manager ensures that CareFirstNY delivers high-quality, compliant, and patient-centered care while championing a commitment to ongoing improvement and organizational excellence.

Duties:

Oversee QAPI Program

• Develop, implement, and manage the hospice’s QAPI program in compliance with Medicare Conditions of Participation (CoPs) and other regulatory requirements.
• Collaborate with leadership to identify and execute Performance Improvement Projects (PIPs) and Quality Improvement Projects (QIPs) aimed at addressing gaps in care and improving patient outcomes, while monitoring and analyzing clinical and operational data to drive enhancements in care quality, safety, and outcomes.
• Facilitate QAPI meetings (minimum quarterly), track progress, and report findings to leadership and key stakeholders.

Data Analysis and Reporting:

• Collect, analyze, and interpret clinical and operational data (e.g., infection rates, falls, hospitalization rates, patient satisfaction, etc.) to drive informed decision making for continuous quality improvement initiatives.
• Responsible for record upkeep and required data reporting to entities such as NYS DOH, NYS Health Commerce System, Quality Action Boards (QAB), Consumer Assessment of Healthcare Providers and Systems (CAHPS), and Hospice Item Set (HIS/HOPE), and Health Emergency Response Data System (HERDS) survey reporting.
• Create reports for leadership, providing insights into performance trends and outcomes of initiatives.

Education and Training:

• Develop and deliver compliance and QAPI training programs for staff to promote awareness and accountability.
• Educate teams on proper documentation, quality metrics, and compliance standards.
• Provide ongoing support and feedback to ensure a culture of quality and compliance.
• Collaborate with leadership to align QAPI and compliance goals with overall organizational objectives.
• Work closely with clinical, administrative, and operational teams to ensure alignment of processes with regulatory and quality requirements.

Patient and Family Satisfaction:

• Oversee the evaluation of patient and family satisfaction surveys and feedback.
• Develop strategies to address concerns and improve patient/family experiences.

Regulatory Compliance:

• Facilitates and leads Compliance Committee and initiatives.
• Stay updated on federal, state, and local regulations impacting hospice care (e.g., Medicare CoPs, HIPAA).
• Conduct regular audits and reviews to ensure policies, procedures, documentation and general practices comply with regulatory standards.
• Coordinate and prepare for internal and external surveys (e.g., CMS, state inspections, accrediting bodies like Joint Commission or CHAP).
• Collaborates with stakeholders in the development and implementation of corrective action plans for any identified deficiencies or gaps.

Emergency Preparedness Program:

• Develop, implement, and regularly update comprehensive plans to assess risks, train staff, maintain resources, coordinate with local agencies, and ensure effective communication, patient care, and response during emergencies, with continuous improvement through post-incident reviews and documentation.

Infection Control Program:

• Establish and maintain robust infection control policies and training programs, aligned with regulations and CDC guidelines, to monitor, prevent, and respond to healthcare-associated infections (HAIs), ensure compliance, support cleanliness, and continuously improve practices through data analysis, audits, and collaboration with staff and authorities.

Policy and Procedure Management:

• Develop, update, and maintain hospice policies and procedures to align with current laws, regulations, and industry best practices.
• Train staff on policies and compliance expectations, ensuring consistency in care delivery and documentation.

Incident and Risk Management:

• Investigate incidents, complaints, and adverse events, ensuring root cause analysis and corrective actions are implemented.
• Identify trends and risks that may affect patient care or organizational compliance.
• Monitor and reduce potential liability through proactive risk management initiatives.

Record Keeping:

• Maintains Physician database in EMR, performs vetting process and sanction checks to ensure organization is legally engaging with providers.
• Ensures the timely completion of physician certifications, orders and discharges through the collection of assigned physician signatures.

Team Management:

• Ensure compliance with state and federal regulations for Hospice and related service lines by serving as a regulatory resource for the hospice team, monitoring adherence to regulations, supervising the timely and accurate completion of documentation, and overseeing audits of patient charts.
• Demonstrates knowledge of payor guidelines (Medicare, Medicaid, private insurance), sliding fee scale, identifying expense or treatment outliers for coverage decisions, and ensures proper utilization of contracted and flex personnel under the guidance of the Director of Hospice Services.
• Maintain expertise in care provisioning and patient assessment, perform admissions and assign care team members as needed, provide field coverage to ensure continuity of patient and family care, and coordinate referrals and collaboration with community agencies.
• Oversee the Interdisciplinary Team, including scheduling, patient admissions, and coordination of IDG meetings to ensure care planning and delivery meets regulatory requirements and best practices.
• Performs supervisory duties (hiring, development, orientation, coaching, evaluation and termination as necessary) for all members of the clinical team. Participates in committees and related program initiatives, sharing key stakeholder knowledge and expertise.

Special Assignments, Rotations, and Schedules:

• Serves as the agency Privacy Officer

Additional Duties:

• Demonstrate compassionate behavior
• Exceptional communication skills
• Able to plan activities and carry them through effectively
• Works well as part of the interdisciplinary team
• Positive attitude about working with families of diverse cultural and religious backgrounds
• Works confidently within a group

Qualifications:

Qualified candidates must possess a valid NY Registered Professional Nurse License with a bachelor’s degree in nursing OR valid NY Master Social Work or Clinical Social Work license. Must have minimum 4 years professional experience in clinical discipline, along with a minimum of 2 years supervisory experience.

CareFirstNY is an Equal Opportunity Employer.

Job Type: Full-time

Pay: $71,175.00 - $79,950.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible schedule
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Professional development assistance
• Retirement plan
• Vision insurance

Schedule:

• 10 hour shift
• 8 hour shift
• Day shift

Experience:

• Registered Nursing: 4 years (Required)
• Social Work: 4 years (Required)
• Supervisory: 2 years (Required)

Work Location: In person

Salary : $71,175 - $79,950