Benefits Employee discounts Health insurance Paid time off Essential Job Functions / Key Responsibilities Documentation Review Works collaboratively with Clinical Team to ensure documentation is complete and consistent with care and reflects legal requirements in real-time. Validate documentation accuracy and appropriateness real-time. Admissions & Discharges Review admissions for physician orders, verbal certification, and complete documentation. Review all discharges including live discharges and patient deaths. Ensure documentation supports regulatory compliance. Ensure regulatory compliance with all admissions and discharges. Validate documentation accuracy and appropriateness. Works collaboratively with Clinical Team to ensure documentation is complete and consistent with care and reflects legal requirements in real-time. Incidents, Falls & Infections Review all incidents including falls and infections. Ensure interventions, reassessments, and care plan updates are completed. Monitor infection tracking and compliance. Conduct root cause analysis and implement prevention strategies. Incidents/ Accidents/ Unusual occurrences/ Infection Control issues Leading interdisciplinary teams to identify and address systemic issues, such as reducing patient falls or medication errors. Care Plan Compliance Audit nursing care plans every 14 days and with condition changes. Ensure plans reflect physician orders and patient condition. Audit HHA care plans every 14 days and with updates. Ensure HHA care plans are updated every 14 days and with changes. Evaluate quality and effectiveness of care plans IDG Documentation Ensure IDG notes are timely and reflects patient status, decline, and plan effectiveness. Deficiency Management Identify, track, and ensure correction of deficiencies. Provide feedback and education to staff timely. Performance Improvement Use audit findings to identify trends and support QAPI initiatives. Ensures that there are processes in place to monitor and measure all activities related to performance improvement. Implements the Agency’s continuous Quality Assessment and Performance Improvement (QAPI) plan and program. Establishes a process model for improvement and provides education and training to organization personnel on the performance improvement plan, as well as team development. Manages quarterly clinical record review process and ensures timely and accurate results. Tabulates and submits findings to the Clinical Director. Trend Analysis Analyze data and implement system-wide improvements. Coordinates activities related to clinical record review for data collection. Collects, tracks and compiles quality indicator data including, but not limited to: Compiles, trends and reports quality data in the following areas: patient care, safety, risk management, infection control, outcomes, and customer satisfaction and reports information to Clinical Director. Regulatory Compliance Ensuring the facility meets standards set by the Centers for Medicare and Medicaid Services (CMS), The Joint Commission, and other accrediting bodies. Responsible for the implementation and monitoring of the organization’s quality improvement program.
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