QAPI Director

Job Overview
We are seeking an energetic and detail-oriented QAPI (Quality Assurance and Performance Improvement) Director to lead our organization’s commitment to delivering exceptional, compliant, and patient-centered care. In this pivotal role, you will oversee the development, implementation, and continuous improvement of quality programs that align with regulatory standards and industry best practices. Your leadership will drive a culture of safety, compliance, and excellence across all operational facets, ensuring adherence to federal and state regulations including HIPAA, Medicare, JCAHO, FDA regulations, and various coding standards. If you thrive on making a meaningful impact through strategic oversight and collaborative leadership, this is your opportunity to elevate healthcare quality standards.

Responsibilities

• Lead the design, execution, and evaluation of comprehensive QAPI initiatives that promote safety, quality, and compliance across all departments.
• Develop and maintain policies and procedures aligned with HIPAA privacy rules, Medicare requirements, FDA regulations, JCAHO standards, and other applicable regulatory frameworks.
• Oversee data collection and analysis related to clinical outcomes, patient safety incidents, and operational performance metrics to identify areas for improvement.
• Collaborate with multidisciplinary teams to implement corrective actions based on audit findings and performance data.
• Ensure accurate documentation of compliance activities including CPT coding, ICD-9/ICD-10/ICD coding procedures, and other billing-related processes.
• Conduct regular staff training on compliance management topics such as HIPAA privacy/security protocols, ICD coding updates, Medicare policies, and FDA regulations.
• Monitor regulatory changes impacting healthcare delivery; update policies accordingly to maintain accreditation standards such as those set by JCAHO.
• Ensuring Life Hospice is complying with the Community Health Accreditation Partner (CHAP) standards and Center for Medicare and Medicaid Services (CMS) conditions of participation and other regulatory licensure requirements
• Leading quality initiatives, ensuring compliance with regulatory standards, and enhancing clinical education within the organization
• Assessment, development, implementation and ongoing evaluation of education for Life Hospice clinical staff
• Foster a culture or continuous improvement to optimize patient outcomes and operational efficiency

Skills

• Extensive knowledge of HIPAA regulations and privacy/security protocols.
• Proficiency in CPT coding, ICD-9/ICD-10/ICD coding systems, with the ability to interpret clinical documentation accurately.
• Strong understanding of Medicare policies and reimbursement processes.
• Familiarity with FDA regulations affecting healthcare products and services.
• Proven experience in compliance management within healthcare settings.
• Knowledge of accreditation standards from organizations such as JCAHO (The Joint Commission).
• Excellent leadership skills with the ability to foster a culture of continuous improvement through collaboration and strategic planning. Join us in shaping a future where quality care is at the heart of everything we do! We are committed to empowering our team members through ongoing education, professional growth opportunities, and a vibrant work environment dedicated to excellence in healthcare delivery.
• Review documentation to identify areas which may have fallen out of compliance and communicates findings and recommendations to Administrator. Collaborate with executive leadership to establish quality improvement priorities and objectives
• Monitor key performance indicators (KPIs) and analyze data to identify areas for improvement
• Design, execute Plan of Correction and/or PIP (Performance Improvement Plan) to bring identified areas to compliance
• Conduct audits and assessments to evaluate compliance and quality of care
• Develop, prepare and lead quarterly QAPI meetings for Life Hospice IDG members. Develop and deliver educational programs and training sessions for clinical staff. Mentor and support staff in best practices for quality improvement and patient care

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance
• Mileage Reimbursement 

QUALIFICATIONS

• Must be a graduate from an accredited School of Nursing.
• Must be licensed in NJ as a Registered Nurse by New Jersey State Board of Nursing in
• accordance with NJSA 45:11-23 et seq and NJAC 13:37.
• One year of RN experience. Hospice experience preferred.
• Must have excellent assessment skills and problem-solving skills.
• Should be skillful in organization and in the principles of time management and have knowledge of case management processes.
• Must be a licensed driver with an insured automobile in good working order.
• The ability to communicate well, both verbally and in writing.