Hospice Alliance
Job Title: Clinical Services Manager
Reports to: Director of Clinical Services
Hours: Core work hours are 8am to 4:30pm, Monday-Friday. May on occasion vary depending on organizational needs.
Remote work for this position is limited.
Participates in the on-call supervisor rotation, which includes rotating weekends and holidays.
CLINICAL SERVICES MANAGER GENERAL DESCRIPTION
Summary
The Clinical Services Manager works collaboratively with the other Clinical Managers, and other
departments within the organization and is responsible for creating and maintaining a positive work
environment and assisting with the day-to-day management of the clinical team. This position has a
focus on the planning, designing, implementing, and maintaining the Hospice Alliance Compliance,
Quality Assurance/Performance Improvement, and Infection Control Programs and, is responsible for
maintaining and monitoring quality assurance data and public reporting. Develops and implements
policies, procedures, total quality management (TQM) activities, reporting, training, completing
supervisory visits, and education to ensure organization-wide compliance with legal, ethical, contractual,
and/or regulatory standards. The Clinical Services Manager also serves as the Infection Control
Practitioner and is responsible for new hire/annual screenings/fit testing and supervises the Education
RN, and other assigned team members.
Physical Demands
This job requires an employee to stand, talk and hear. When performing patient care there is frequent
standing and walking, and occasionally an RN is required to sit, bend, kneel, stoop or crouch. This
position requires frequent use of hands and fingers and may require reaching in front or above
shoulders, feeling, or grasping. The employee will frequently lift to 35 pounds, and occasionally move
100 pounds.
Work Environment
Most work is performed in the Hospice Alliance office. Exposure to long-term computer use/viewing and
sitting for extended periods.
Some work may be performed in the Hospice Alliance (HA) residential facility, patient homes, skilled
nursing facilities or any other place that a patient calls home. There is a potential for exposure to
animals, smoke, unpleasant odors and a vulnerability to contagious diseases or infections. This position
requires driving which may present danger in inclement weather.
ESSENTIAL DUTIES AND RESPONSIBILITES
Quality Assurance and Performance Improvement
- Conducts an ongoing, comprehensive, integrated organizational assessment of the quality and
appropriateness of the care provided, including services provided under agreement. - Develops and presents performance improvement projects.
- Compiles results of all PQRS Quality Requirements (CAHPs Survey and HIS Data) and presents
results for quarterly review and benchmarks against any available national data. - Aggregate and trends data collected to correct identified relating to patient care and safety,
infection control and outcomes. - Prepares and presents the annual Quality Improvement report as part of annual organizational
evaluation requirements and for biannual board meetings. - Implements quality improvement programs with the department directors, managers and
supervisors and delegates’ responsibilities to appropriate personnel. - Participates in activities directed at improving patient and staff safety and provide data for
reporting, tracking, and trending. - Conducts clinical record reviews and completes required reporting tools within designated time
limits. - Chairs QAPI committee; prepares QAPI reports/minutes of meetings according to QAPI plan.
- Coordinate the initial and annual HHA Competency Training and Evaluations. Update the HHA
CEU (Continuing Education Units) & Competency Evaluation tracking report. Ensure the tracking
report monthly. - Assist in conducting mock surveys of the program as required.
- Coordinate the regulatory compliance requirements for vendor and facility contracts. Discuss
areas in need of improvement at management meetings. - Oversee the Policy and Procedure Manual and ensure policies are reviewed per policy
Compliance
- Responsible for annual/ongoing updates to the Compliancy Group for our HIPAA compliance
recertification. - Demonstrates in-depth knowledge of, and ensures compliance with, all local, state, and federal
laws relating to the organization’s operations. - Collaborates with appropriate personnel on issues related to risk management and compliance.
- Provides regulatory compliance training to staff within specified time limits.
- Reports compliance concerns/issues to compliance management or designee.
- Investigates and resolves identified regulatory compliance concerns.
- Investigates and resolves all complaints following the HA policy/procedure/guidelines.
- Provides feedback to management regarding identified problem areas and facilitates the
development of action plans for their resolution. - Participates in the development of and conducts follow-up audits because of internal review
findings. - Reviews and analyzes Medicare Additional Development (ADR) Requests to ensure appropriate
response to the Medicare Administrative Contractor. - Reviews and analyzes ADR/denial logs to help identify staff training needs or additional internal
reviews. - Assists in identifying areas of potential medical/legal risk and may participate in developing an
appropriate response or action plan. - Evaluates clinical documentation to ensure professional standards of practice, regulatory
compliance, and reimbursement standards are met. Identifies areas for improvement/training. - Responsible for reporting and ensuring state caregiver misconduct reporting requirements are
being followed. - Oversee Compliancy website and certification
Infection Control
Serves as the organizations Infection Preventionist, and completes and/or provides proof of CDC (Centers for Disease Control) certification within 3 months of hire
- Provides employee and volunteer health and infection control screenings to include TB and
communicable disease screening forms, immunization evaluation, exposure control, and refer
for appropriate follow-up as needed. - Completes annual fit testing for all staff that have or may have patient contact.
- Develop, implement, and monitor infection control policies and procedures.
- Conducts observational data collection, surveillance, documents, and reports findings.
- Collaborates with central supply team members regarding PPE (Personal Protective Equipment)
- Interact with Interdisciplinary team members to provide infection control, surveillance, and
prevention. - Tracks all COVID positive employees along with masking and RTW dates/instructions.
GENERAL DUTIES
- During scheduled and unscheduled absences, assists with triaging of calls, along with the other
Clinical Managers and assigns additional visits to clinical staff as needed. - Responds to the day-to-day needs of the clinical team, including guiding practice decisions,
assisting with medication approvals, and providing support to the staff. - Participate in assigned Wisconsin Hospice Collaborative Work teams and attend meetings as
required. - Participates in the on-call supervisor rotation and must perform patient care duties when needed.
- Provides patient care duties as needed.
- Maintain a positive work environment by acting and communicating with internal and external
contacts in a manner that actively promotes teamwork, problem resolution and customer satisfaction. - Participates in new employee orientation
- Provides training QAPI, Compliance and Infection Control training in identified areas to
employees and volunteers. - Serves as a role model for ethical behavior and high moral standards
- Updates the MSDS drive quarterly and stores drive in an accessible location in case online
access to the MSDS database is not possible. - Tracks and schedules all CPR certification classes.
- Serves as the Hospice Alliance Civil Rights Officer in compliance with Section 1557 of the Patient
Protection and Affordable Care Act. - Other duties as assigned.
EDUCATION AND/OR EXPERIENCE/LICENSING REQUIREMENTS
- Graduate of an accredited school of nursing, BSN preferred.
- Valid license as a Registered Nurse in the State of Wisconsin.
- Valid driver’s license and automobile insurance.
- Prior experience in a compliance and/or QAPI role preferred.
- Certification as a Certified Hospice and Palliative Care Nurse (CHPN) desired.
- Current Basic Life Support Certification.
- Prior palliative care, home health and/or hospice experience is highly desirable.
- Able to cope with emotional stress and be tolerant of individual lifestyles.
- Good written and verbal communication skills
- Sensitive to the needs of terminally ill patients and families and one’s own feelings about dying
and death. - Excellent time management and organizational skills are essential.
- Critical thinking skills and ability to solve problems.
- Strong computer skills are required, such as email, Microsoft Excel, Word, and prior experience
working with electronic medical records