Quality Assurance Nurse at Dover Hospice – Shorewood, Illinois

Position Summary:

The Quality Assurance Registered Nurse (Hospice), reporting directly to the Executive Director, is

responsible for overseeing, monitoring, and improving the quality, safety, and regulatory

compliance of hospice clinical services. This role ensures compliance with all federal, state, and

accreditation standards while supporting continuous performance improvement across the

hospice program. The Quality Assurance RN works collaboratively with clinical leadership,

interdisciplinary team members, and operational staff to support high-quality, patient-centered

end-of-life care, accurate documentation, and timely submission of required quality reporting

measures, including HOPE (Hospice Outcomes & Patient Evaluation) data.

Essential Duties:

The following duties are normal for this position. This list is not to be construed as exclusive or all inclusive. Other duties

may be required and assigned. Reasonable accommodations may be made to enable individuals with disabilities to

perform the essential functions.

• Oversees and supports the hospice Quality Assessment and Performance Improvement (QAPI) program in accordance with CMS requirements.
• Conducts routine and targeted clinical record audits to ensure documentation accuracy, completeness, timeliness, and compliance with CMS Conditions of Participation, agency policies, and accepted hospice standards of practice.
• Identifies trends, risks, and opportunities for improvement related to clinical quality, patientsafety, and regulatory compliance.
• Develops, implements, and monitors Performance Improvement Projects (PIPs) in collaboration with hospice leadership to address identified quality, safety, and complianceopportunities.
• Participates in data collection, analysis, monitoring, and reporting for hospice quality initiatives and regulatory requirements.
• Oversees hospice compliance with HOPE (Hospice Outcomes & Patient Evaluation) reporting requirements, including timely completion of assessments, monitoring submission deadlines, and ensuring data integrity.
• Educates and supports clinical staff on HOPE documentation standards, quality reporting expectations, and regulatory updates.
• Monitors hospice quality metrics, including pain and symptom management, care planning and coordination, and patient and caregiver experience.
• Reviews open and closed hospice charts to ensure documentation supports terminal prognosis and eligibility, level of care determination, and Interdisciplinary Group (IDG) decision-making.
• Provides feedback, education, and corrective guidance to clinicians regarding documentation standards and timeliness requirements.
• Provides ongoing education and training related to hospice documentation standards, regulatory requirements, quality improvement initiatives, and HOPE reporting.
• Assists with orientation and onboarding of new clinical staff related to quality andcompliance expectations.
• Maintains hospice survey readiness and assists with preparation for, participation in, and follow-up from state, CMS, and accreditation surveys.
• Reviews and recommends updates to agency policies and procedures to maintain regulatory compliance and support quality improvement.
• Collaborates with hospice leadership, clinical managers, and IDG members to support high-quality, patient-centered care delivery.
• Supports leadership in evaluating clinical performance and identifying opportunities for improvement.
• Promotes patient, staff, and environmental safety and monitors compliance with infection control and safety policies.
• Identifies and escalates safety concerns, adverse events, and potential compliance risks.
• Always ensures patient confidentiality and HIPAA compliance.
• Other duties as assigned.

Qualifications, Education and/or Experience:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills, and abilities required.

• Current, unencumbered Registered Nurse (RN) license in the state(s) of practice is required.
• Strong working knowledge of CMS Hospice Conditions of Participation (CoPs) is required.
• Experience with hospice documentation, IDG processes, and quality audits is required.
• Knowledge of hospice reimbursement, quality reporting, and compliance requirements is
• required.
• Experience with or strong understanding of HOPE reporting is strongly preferred.
• Excellent written and verbal communication skills are required.
• Strong analytical, organizational, and problem-solving abilities are required.
• A valid driver’s license, reliable transportation, and current auto insurance are required.
• Commitment to Dover Health’s mission and values.

Working Conditions: As part of Dover Health’s commitment to providing outstanding care and support, the company ensures that staff work under conditions that prioritize safety, collaboration, and professional growth. The conditions listed below define the experience of working for Dover Health. This position may involve a range of physical activities, including those outlined in the Essential Duties, but is not limited to them.

• Frequent travel within assigned service area is required.
• While performing the duties of this job, the employee is occasionally required to stand for extended periods of time, move, communicate, and identify written information. The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl and lift and/or move up to fifty (50) pounds independently, and occasionally lift and/or move up to two hundred (200) pounds with assistance.
• Work for this position is performed in patient homes, care settings/facilities, and office settings. This position will have to navigate through a variety of different settings to provide care.
• There is exposure to varied home environments and potential infectious conditions.
• Must comply with all Dover Health health and safety requirements.
• This role involves actively participating in all staff activities aimed at fostering teamwork, unity, and morale. The individual will contribute as a collaborative team player, working alongside colleagues to create a supportive and cohesive work environment.
• Individuals in this position are required to stay current on all training and ongoing education initiatives. They are expected to actively pursue self-improvement and embrace opportunities for continuous learning to enhance their skills and knowledge in providing exceptional service.

We are an Equal Opportunity Employer. In compliance with the Americans with Disabilities Act, we will provide

reasonable accommodations to qualified individuals with disabilities and encourage prospective employees

and incumbents to discuss potential accommodations with the employer.