Quality Assurance & Performance Improvement Nurse QAPI Nurse

Oasis Hospice And Palliative Care Inc.; Homewood (IL); On-site; USD 75,000 - 98,000; Full time

Benefits offered by this job

Employee discounts

Health insurance

Paid time off

Job summary

Oasis Hospice And Palliative Care Inc. is seeking a registered nurse to lead clinical documentation reviews, ensuring real-time accuracy and compliance with CMS and CHAP standards.

The role collaborates with the clinical team on admissions, discharges, and care plans, auditing every 14 days and driving performance improvement. Requirements include IL RN licensure, BSN, 3-5 years of nursing experience with hospice exposure, and leadership capabilities.

Qualifications

• Current and active RN licensure to practice in IL.
• BSN degree required; MSN preferred.
• 3-5 years of clinical nursing experience, with 2+ years in hospice/palliative care and 1+ year in leadership/management.
• Knowledge of hospice regulations, CHAP, CMS conditions, and regulatory standards.
• Strong understanding of clinical documentation and charting standards.

Responsibilities

• Review admissions for physician orders, verbal certifications, and complete documentation.
• Audit care plans every 14 days and with condition changes.
• Lead performance improvement initiatives and QAPI program implementation.
• Coordinate IDG documentation to reflect patient status and plan effectiveness.
• Identify, track, and correct deficiencies; educate staff on improvements.

Skills

Regulatory knowledge

Clinical leadership

Interdisciplinary teamwork

Documentation accuracy

Education

BSN required

MSN preferred

Job description

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.

POSITION QUALIFICATIONS

1. Current and active RN licensure to practice professional nursing in IL State.
2. BSN required, MSN and/or healthcare leadership certification preferred.
3. Minimum of 3-5 years of Clinical nursing experience, with at least 2 years in Hospice care or palliative care, and 1 years in nursing leadership and/or management.
4. Knowledge of hospice philosophy, end-of-life symptom management, interdisciplinary team care, governmental regulations, and CHAP standards, Medicare Conditions of Participation, governmental regulations and business management.
5. Strong understanding of hospice regulations, charting standards, and clinical documentation.