Position: Regional Quality Assurance Specialist (RN)
Department: Nursing
Reports to: Vice President of Clinical Services
FLSA Status: Salary/Exempt
Purpose of Your Job Position
The Regional Quality Assurance (QA) Specialist is a high-level clinical role responsible for fostering a culture of excellence and ensuring substantial compliance with federal, state, and local regulations across multiple skilled nursing facilities. This individual will conduct thorough clinical audits, identify opportunities for improvement (QAPI), and develop, implement, and follow up on action plans to ensure compliance and quality resident care.
The role partners with Administrators, Directors of Nursing, and clinical leadership teams to provide education, guidance, and quality oversight. This position provides recommendations and education related to clinical findings but does not assume operational responsibility for facility clinical leadership.
Delegation of Authority
As Regional Quality Assurance (QA) Specialist, you are delegated the authority, responsibility, and accountability necessary to carry out your assigned duties. You will work collaboratively and professionally with the VP of Clinical Services, DONs, Administrators, and other facility leaders to support clinical education initiatives across the organization.
Job Function
Every effort has been made to identify the essential functions of this position. However, this does not state or imply that these are the only duties required. Duties may be modified, expanded, or assigned as necessary to meet organizational needs.
Duties and Responsibilities:
Administrative Functions: Clinical Auditing & Surveillance
- Conduct in-depth audits of medical records including, but not limited to:
- medication administration
- Infection control practices
- skin integrity management system
- weight management system
- fall prevention programs and systems
- Review risk reports, root cause analyses, medical record reports and trends.
- Provide written and verbal reports to the VP of Clinical Services regarding facility visits and risk areas.
- Assist, as needed, in education related to policy updates, regulatory changes, and clinical initiatives.
- Maintain an electronic copy of education records for all education provided.
- Review and maintain monthly reports submitted by the centers. Monitor for facility and corporate-wide trends.
Clinical Competency Functions
- Conduct competency validations in targeted buildings or high-risk areas as directed.
- Perform follow up to assure compliance with clinical initiatives as directed.
Survey Readiness and Regulatory Education
- Provide focused education on survey-risk areas including documentation, infection prevention, medication administration, abuse prevention, clinical systems, and resident rights.
- Reinforce regulatory expectations through ongoing auditing and clinical education.
- Assist in the monitoring of systems to ensure compliance with CMS and state regulations.
- Support mock surveys and assist with competency validation tied to potential identified deficiencies.
- Assist centers with education related to survey citations and implementation and monitoring of corrective action plans.
- Act as a clinical resource during urgent situations, such as infection outbreaks, self-imposed immediate jeopardy or regulatory situations.
Clinical Initiative and Program Implementation
- Partner with the VP of Clinical Services to operationalize system clinical initiatives through education and competency validation.
- Support consistent implementation of policies, clinical practices, and quality initiatives across centers.
- Serve as an education liaison between corporate clinical leadership and facility teams.
Leadership and DON Support Functions
- Assist with development of nurse leaders.
- Support education needs in underperforming or high-risk centers.
- Provide resources and clinical education support to facility leadership.
- Partner to develop strategies tied to performance improvement.
Quality Improvement and QAPI Functions
- Identify education opportunities based on quality metrics, clinical audits, and trends.
- Support QAPI initiatives through targeted education and competency validation.
- Collaborate with clinical leadership to address recurring practice gaps.
- Support facility QAPI committees in analyzing data and developing sustainable action plans.
- Ensure that corrective action plans are implemented effectively, worked appropriately with all necessary supporting documentation, and monitored for sustainability.
- Track and report audit results, trends, and follow-up data to the VP of Clinical Services.
Committee Functions
- Serve on and participate in corporate and facility committees as assigned.
- Provide educational support for initiatives, as needed.
- Assist with implementation of recommendations related to clinical education.
- Participate in meetings as directed by the VP of Clinical Services.
Educational Functions
- Assist in planning and conducting in-service education programs across centers, as needed.
- Validate, and support as needed, annual required education and competency validation programs.
- Provide education resources for clinical leadership.
- Support centers with Skills Fairs.
Working Conditions
- Works in office settings as well as throughout assigned centers.
- Frequent travel to assigned facilities is required, generally four days per week.
- Must be able to professionally interact with residents, staff, physicians, leadership, and regulatory agencies.
- May work beyond normal hours as needed to support clinical initiatives and regulatory compliance.
Education
- Must possess a current, unencumbered Registered Nurse license in applicable state(s).
Experience
- Minimum of three (3) years of clinical nursing experience in long-term care / skilled nursing.
- Must have experience in leadership role in long-term care / skilled nursing.
- Multi-facility or corporate experience preferred.
Specific Requirements
- Knowledge of long-term care regulations and standards of practice.
- Ability to travel to all centers.
- Strong organizational, professional communication, and teaching skills.
- Ability to make independent decisions and work collaboratively with leadership.
- SPICE certification preferred for North Carolina facilities or willingness to obtain certification at the next scheduled SPICE class.
- Must be willing to be on call to answer questions, as needed.
Physical and Sensory Requirements
(With or Without a Reasonable Accommodation)
- Must be able to walk, sit, stand, and bend intermittently throughout the workday.
- Must be able to see and hear or use prosthetics that will enable these senses to function adequately to ensure that the requirements of this position can be fully met.
- Must function independently and have flexibility, personal integrity, and the ability to work effectively with residents, personnel, and support agencies.
- Must meet the general health requirements set forth by the policies of the Company, which may include a medical and physical examination.
- Must be able to relate to and work with the ill, disabled, elderly, emotionally upset, and, at times, hostile people within the Facility.
- May be necessary to assist in the evacuation of residents during emergency situations.
- Based on the Occupational Safety and Health Administration's Guidelines for Nursing Homes Ergonomics for the Prevention of Musculoskeletal Disorders and the American Conference Governmental Industrial Hygienists' Threshold Limit Values for Lifting the Facility has identified that this job may require the lifting of residents, equipment, or other objects. Accordingly, this job may require a minimum of 5 pounds and a maximum of 45 pounds lifting, periodically and or as needed.