Job Description

ESSENTIAL DUTIES AND RESPONSIBILITIES

Quality and Performance Improvement
• Monitor, analyze, and report daily clinical performance data, trends, and outcomes.
• Performs daily rounding on the units to identify performance gaps and recommend evidence-based interventions as appropriate.
• Assist with developing, implementing, and evaluating quality improvement initiatives to enhance patient care and safety.
• Assist with ongoing quality improvement initiatives to improve resident care outcomes, reduce hospitalizations, and support five-star quality measures.
• Conduct data analysis on incidents, falls, infections, pressure injuries, medication errors, and other quality indicators.
• Facilitate root cause analysis and develop corrective action plans.
• Maintain accurate documentation of QI activities, results, and action plans.
• Utilize Electronic Health Records (EHR), other systems, and quality databases, to track and trend performance outcomes.
• Assist with the facilities Quality Assurance and Performance Improvement (QAPI) program, document meeting minutes of QAPI projects, and present findings to the Quality Assurance (QA) committee.

Compliance/Risk and Safety
• Conduct regular audits to ensure compliance with organizational policies and external regulatory standards, for example Centers for Medicare and Medicaid Services (CMS), The Joint Commission.
• Review medical records for accuracy, completeness, and adherence to protocols.
• Ensure compliance with CMS regulations, state survey requirements, infection control standards, and facility policies.
• Participate in surveys, prepare required documentation, and support corrective action plans.
• Conduct audits such as medication pass, infection control rounds, and chart reviews.
• Collaborate with Interdisciplinary Teams (IDT) to improve workflow efficiency and patient care processes.
• Participate in committee meetings, Risk Management and Quality Assurance (RMQA), and other meetings as required.
• Support staff by delivering expertise in QI processes and patient safety initiatives.
• Provides training, coaching, and real-time feedback to clinical staff regarding documentation standards, care protocols, and compliance expectations.
• Contributes to fostering a culture of quality, safety, and accountability throughout the care continuum.

Clinical Support
• Assists with policy and procedure updates to ensure evidence-based and regulatory-aligned practices are maintained.
• Weekend and off-hour rounding to ensure full compliance with clinical operations on a 24/7 basis.
• May be required to assume clinical staff coverage on the unit during periods of staffing challenges.
• Performs all other duties as assigned.

SUPERVISORY RESPONSIBILITIES
This role may provide supervision to team members on a situational basis.

This position requires a background screening through the Care Provider Background Screening Clearinghouse. For information on the requirements, please visit the Clearinghouse Education and Awareness website at

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