RN Quality Analyst

Company Information

At Community Hospice & Health Services and its affiliates, Community Hospice & Health Services Foundation, and CHI Management, Inc. (herein referred to collectively as “CHHS”) you will find a family-based and compassionate work environment. Our goal is to provide a wonderful work experience that allows our employees to thrive by feeling engaged and fulfilled each day. CHHS is the largest and oldest nonprofit hospice, palliative care, and support services provider in the Central Valley.

We are proud to indicate that CHHS has been supporting and providing compassionate and quality services to our community since 1979. Our mission is to embrace individuals and families facing life-changing journeys, enhancing quality of life for all. CHHS is accredited by Community Health Accredited Program (CHAP).

Department: Integrated Quality Services

Reports To: Quality and Compliance Manager

Summary: This position directly supports the Quality and Compliance Manager and serves quality assessment and performance improvement (QAPI) initiatives, risk management, regulatory compliance, and patient safety programs. The RN Quality Analyst reviews clinical data, monitors trends, and compiles comprehensive reports to drive continuous quality improvement efforts and maintain compliance with federal, state, and Community Hospice & Health Services (CHHS) policies.

RESPONSIBILITIES:

• Extracts and collects data from Electronic Health Records (EHR) and clinical databases to prepare reports, run statistical analyses, and create visual graphs related to audit outcomes.
• Addresses audit items as an opportunity for problem identification, for trends, for system review and improvement and for clinical team education.  
• Creates and maintains tracking systems for Quality and Compliance department activities. Data is accurately logged within two (2) working days of receipt.
• Utilizes appropriate QAPI methodologies (e.g., Lean, Six Sigma, Root Cause Analysis) for the evaluation and presentation of CHHS clinical indicators.
• Performs supervised clinical field visits when assigned, to ensure hospice services, patient care, and clinical documentation strictly align with professional standards, California Title 22, and Medicare Conditions of Participation (CoPs).
• Provides coaching and educational support to management and clinical staff regarding QAPI tools, data collection methods, and audit trends
• Completes special projects and generates compliance reports on determined cadences to include daily, weekly, monthly, quarterly, and ad hoc reporting and presentations as delegated by leadership.
• Manages submission workflows for the Hospice Quality Reporting Program (HQRP), including Hospice Item Set (HIS) data, Hospice Outcomes and Patient Evaluation (HOPE) Tool data and CAHPS benchmarks.
• Supports Risk Management & Safey by participating in the investigation of adverse events, performs root cause analyses, and assists in developing corrective action plans.
• Contributes to survey readiness by supporting leadership during state, federal, or accreditation surveys by auditing charts, facilitating data requests, and participating in the live survey process.
• Maintains confidentiality. Assembles and maintains highly confidential departmental files and records in strict compliance with HIPAA and privacy regulations.
• Follows all CHHS policies and procedures including, but not limited to, safety, infection control, privacy and confidentiality, and HIPAA.
• Maintain a professional appearance of self and a working area that is organized.  Exhibits appropriate behavior with internal and external customers, i.e., courteous and professional always.

SUCCESS FACTORS:

• Accuracy, productivity, dependability and good attendance are required.
• Ability to proof own work and provide ongoing quality improvement for assigned work.
• Ability to develop and maintain cooperative, constructive relationships with co-workers.
• Ability to follow through on outstanding issues.
• Understanding of the need for timeliness.
• Ability to maintain a high volume of work on a consistent basis.
• High-level clinical acumen to accurately discern the validity, quality, and compliance of audited medical charts.
• Strong ability to review complex datasets and translate them into clear, actionable clinical insights.
• Exceptional attention to detail, accuracy, and proofreading skills.
• Ability to work independently with minimal supervision while managing a high volume of work.
• Flexible prioritization skills to respond to shifting regulatory deadlines or urgent survey timelines.
• Strong interpersonal skills to build cooperative relationships across clinical and administrative teams.

• Associate’s Degree in Nursing (AND) required; Bachelor of Science in Nursing (BSN) or higher preferred.
• Minimum of two (2) years of clinical RN experience. Experience in hospice, home health, or a clinical quality data/improvement role within the past five (5) years is highly preferred.
• Active, unencumbered Registered Nurse (RN) license in the State of California.
• Certified Professional in Healthcare Quality (CPHQ) or Lean/Six Sigma training.
• Strong working knowledge of Medicare Conditions of Participation (CoPs), California Title 22, The Joint Commission (TJC) or CHAP standards, and National Patient Safety Goals.
• Advanced proficiency with Microsoft Office Suite (Excel, Word, PowerPoint) and experience utilizing clinical EHR systems (e.g., Homecare Homebase, MatrixCare, NetSmart).
• Knowledge of QAPI tools.
• Medical terminology.
• Outstanding verbal and written communication skills.

WORK ENVIRONMENT: This position performs work in an office environment using a computer and general office equipment. 

WORK SCHEDULE: Position is regular full-time required to work a regularly scheduled 40-hour workweek, with overtime required to meet patient needs.  Position may also require rotating weekends and holidays. Part-time (20 – 31 hours per week) or temporary positions may be occasionally utilized, if justified by department needs.