Hospice Quality Assurance Education Nurse

Willow Branch Hospice; Park Ridge (IL); On-site; USD 85,000 - 110,000; Full time

Job summary

Willow Branch Hospice is seeking a Quality Assurance/Education Nurse to support quality improvement, regulatory compliance, and clinical education across the organization. The role reviews documentation for Medicare CON, state regulations, and accreditation standards while promoting excellence in patient care.

The position leads field audits, competency validation, orientation programs, EMR training, and performance improvement initiatives, partnering with clinical leadership to address

Qualifications

• RN license (unrestricted) required; BSN preferred.
• Minimum of two years hospice experience.
• CHPN certification preferred.
• Experience in quality assurance, education, or staff development is desirable.

Responsibilities

• Perform clinical record audits for regulatory compliance and documentation accuracy.
• Review admissions, certifications, plans of care, and discharge records.
• Provide field coaching and competency validation during visits.
• Develop and deliver orientation and continuing education for staff.
• Facilitate EMR training and maintain educational records.
• Lead quality improvement projects and monitor implementation outcomes.
• Assist with survey readiness and regulatory inspections.

Skills

Regulatory compliance

Clinical auditing

Education & teaching

Field coaching

Data analysis

Quality improvement

Documentation review

Interdisciplinary collaboration

Communication skills

Microsoft Office

Education

RN license (unrestricted)

BSN preferred

CHPN preferred

Tools

EMR systems

Microsoft Office

Job description

The Quality Assurance/Education Nurse is responsible for supporting organizational quality improvement, regulatory compliance, clinical education, and performance improvement initiatives. This position reviews clinical documentation for compliance with Medicare Conditions of Participation, state regulations, accreditation standards, and organizational policies while promoting excellence in patient care.

The Quality Assurance/Education Nurse assists with audits, quality measure monitoring, competency assessments, orientation programs, continuing education, EMR training, and performance improvement activities. This position collaborates closely with clinical leadership to identify educational opportunities, reduce documentation deficiencies, improve care outcomes, and ensure survey readiness.

This role serves as both an educator and compliance resource, providing direct field support, mentoring, observational coaching, and competency validation for interdisciplinary team members throughout the organization. The position routinely conducts field audits and accompanies clinical staff in the care setting to promote best practices, regulatory compliance, and quality patient outcomes.

Success in this role is measured through survey outcomes, audit compliance rates, quality indicator performance, employee competency completion, staff development, and adherence to organizational compliance standards.

Essential Functions:

Quality Assurance & Clinical Auditing

• ·Conduct routine clinical record audits for regulatory compliance and documentation accuracy.
• ·Review admissions, recertifications, physician certifications, plans of care, interdisciplinary documentation, medication reviews, and discharge records.
• ·Identify trends, documentation deficiencies, and areas requiring improvement.
• ·Complete pre-bill audits and compliance reviews as assigned.
• ·Ensure compliance with Medicare hospice regulations, Conditions of Participation, organizational policies, and accreditation standards.
• ·Assist with implementation and monitoring of corrective action plans.
• ·Track audit findings and communicate trends and recommendations to leadership.
• ·Monitor documentation timeliness, accuracy, and regulatory compliance.
• ·Assist in preparation for state, federal, and accreditation surveys.

Field Education, Clinical Support & Field Auditing

• ·Conduct field visits with nurses, social workers, chaplains, hospice aides, and other interdisciplinary team members to evaluate clinical practice and provide real-time coaching and education.
• ·Complete competency-based field observations to assess clinical skills, regulatory compliance, documentation practices, and adherence to organizational policies.
• ·Provide one‑on‑one education and mentoring to newly hired clinicians during orientation and onboarding.
• ·Accompany staff on patient visits when additional education, support, or performance improvement interventions are needed.
• ·Conduct field audits in patients' homes, assisted living communities, skilled nursing facilities, rehabilitation facilities, hospitals, and other care settings.
• ·Validate compliance with hospice Conditions of Participation, medication management standards, infection prevention protocols, care planning requirements, and organizational policies during field visits.
• ·Identify opportunities for clinical improvement and provide immediate feedback and corrective guidance.
• ·Monitor implementation and sustainability of corrective action plans through follow‑up field visits and audits.
• ·Serve as a clinical resource for staff requiring support with complex patient care, documentation requirements, regulatory compliance concerns, and best practices.
• ·Collaborate with Clinical Managers, Directors, and the Director of Clinical Services to address performance concerns identified through audits and observations.
• ·Conduct supervisory visit observations and aide competency validation activities as assigned.
• ·Support clinicians in improving clinical assessment, symptom management, care planning, and documentation practices.
• ·Assist with preparation of staff for survey interviews and field survey activities.

Education and Staff Development

• ·Coordinate and facilitate orientation programs for clinical employees.
• ·Develop and present educational programs for nursing, social work, chaplaincy, hospice aides, volunteers, and support staff.
• ·Provide EMR education and documentation training.
• ·Coordinate and validate annual competency assessments.
• ·Develop individualized education and remediation plans when performance gaps are identified.
• ·Maintain educational records and competency documentation.
• ·Coordinate mandatory annual education programs and regulatory training requirements.
• ·Assist leadership with onboarding, mentoring, and retention initiatives.
• ·Develop educational tools, reference materials, skills checklists, and competency validation resources.
• ·Promote evidence‑based practice and continuous professional development.

Quality Improvement & Performance Improvement

• ·Participate in Quality Assessment and Performance Improvement (QAPI) activities.
• ·Assist with quality indicator monitoring and reporting.
• ·Collect, analyze, and interpret quality outcome data.
• ·Participate in root cause analyses and corrective action initiatives.
• ·Monitor hospice quality measures and recommend improvement strategies.
• ·Assist with development, implementation, and monitoring of performance improvement projects.
• ·Track quality outcomes and educational interventions to evaluate effectiveness.
• ·Participate in organizational initiatives designed to improve patient outcomes and regulatory compliance.

Regulation Compliance & Survey Readiness

• ·Maintain current knowledge of federal, state, and accreditation regulations affecting hospice operations.
• ·Assist leadership in preparing for state, federal, and accreditation surveys.
• ·Participate in mock surveys and compliance reviews.
• ·Monitor implementation of policies and procedures.
• ·Assist with investigation of complaints, incidents, and quality concerns.
• ·Support corrective action development following audits, surveys, and compliance reviews.
• ·Educate staff on regulatory updates and compliance expectations.
• ·Participate in survey response and follow‑up activities as needed.

Documentation, Reporting and Compliance

Must complete a minimum of six (6) hours of initial training within the first 60 days of employment as required by the Alzheimer's Disease and Related Dementia Services Act.

• ·Prepare quality assurance reports for leadership and QAPI meetings.
• ·Maintain audit logs, quality improvement records, educational files, and competency records.
• ·Track staff education completion and competency requirements.
• ·Monitor and report audit trends, quality indicators, and educational outcomes.
• ·Maintain confidentiality of patient, employee, and organizational information.
• ·Complete required education and compliance training.
• ·Other duties as delegated by supervisor.

Qualifications/Skills/ Educational Requirements:

Level of Formal Education: Bachelor of Science in Nursing (BSN) preferred.

Area of Study: Nursing

Years of Experience: Minimum of two (2) years hospice experience required.

Type of Experience: Experience in hospice clinical practice, quality assurance, compliance, education, clinical management, or staff development preferred.

Special Certifications: Current unrestricted Registered Nurse license.

CHPN preferred.

Language Skills: Effective verbal and written communication skills in English.

• ·EMR documentation and chart review.
• ·Clinical auditing and compliance review.
• ·Data collection and analysis.
• ·Microsoft Office applications.
• ·Quality reporting systems.

Skills and Abilities:

• ·Strong knowledge of Medicare Hospice Conditions of Participation.
• ·Knowledge of state and federal hospice regulations.
• ·Strong auditing and documentation review abilities.
• ·Excellent presentation, coaching, and teaching skills.
• ·Strong attention to detail.
• ·Effective critical thinking and problem‑solving abilities.
• ·Ability to interpret clinical and operational data.
• ·Strong organizational and time‑management skills.
• ·Ability to manage multiple priorities and projects simultaneously.
• ·Ability to maintain confidentiality and professional integrity.
• ·Ability to function independently while collaborating effectively with interdisciplinary team members.
• ·Ability to mentor staff and provide constructive feedback.
• ·Strong written and verbal communication skills.
• ·Ability to influence clinical practice through education and coaching.

Information Systems:

Proficient computer skills with EMR, Microsoft Office, email, and database management systems.