Director, Quality Improvement & Compliance

Employment Type:
Full timeShift:
Description:
Director, Quality Improvement and Compliance
Location: Saint Joseph PACE
Status: Full time
Shift: Monday-Friday, Typically 8a-5p
Incentives: 1st Day Benefits
Position Purpose:
The primary purpose of your job position is to develop, implement, organize, and monitor the Quality Assurance and Performance Improvement Plan (QAPI) for the PACE Organization (PO) and ensures overall CMS regulatory compliance. The Director, Quality Improvement and Compliance, in collaboration with the Medical Director, is responsible for developing and implementing the annual QAPI plan, including leading quality initiatives and projects. In addition, the Director ensures that data is collected from appropriate sources, is examined and results are shared with all stakeholders.
Position Details:
This position will be onsite at Saint Joseph PACE.
What you will do:

• In conjunction with Medical Director, initiates, develops, and guides the implementation of the annual Quality Assurance Performance Improvement plan (QAPI). Compiles annual report and shares results with leadership, staff, contractors, administration, the Participant Advisory Committee (PAC), and Board of Directors.
• Assist with scheduling and coordination of the PACE Quality Management Committee in collaboration with Medical Director. Duties include preparation of meeting agenda, preparation of minutes, and assistance with committee correspondence and presentation materials.
• Assure annual review and approval of Infection Control plan.
• Communicate the QAPI plan to members, staff, contractors, administration, Participant Advisory Committee (PAC), and the Board of Directors.
• Ensure compliance with CMS regulations. Has overall responsibility for the Medicare Part D fraud, waste and abuse Compliance Program. Assure annual review and approval of Compliance plan. Ensure that colleagues complete the activities and responsibilities identified in the Compliance program and those related to the HIPAA privacy rule.
• Manage preparation for CMS sites visits, inspections, and all subsequent follow up activities.
• Analyze risk management data and QAPI data in order to identify and control loss.
• Coordinates and maintains all activities pertaining to complaints, service delivery requests, and grievances/appeals, assures regulatory compliance and incident reporting including trend analysis for necessary action plans and Quality Improvement initiatives.
• Plan, develop, organize, implement, evaluate, coordinate, and direct our infection control program in accordance with current rules, regulations, and guidelines that govern such requirements.
• Prepare monthly summaries of all participant/personnel infections, corrective action taken, and the results of thecorrective action.
• Lead and facilitate Participant Satisfaction and HOS survey process and analyze data.
• Ensure accurate and timely reporting to CMS, State, and all other Trinity Health PACE reporting requirements.
• Daily monitoring of HPMS complaints and memorandums for quality and compliance updates. Coordinate any necessary actions per HPMS memorandum guidance.
• Prepare and submit monthly quality metrics reporting to Trinity Health PACE and participates in Trinity Health PACE initiatives, meetings, and programs as required.
• Assist staff in establishing process evaluation, including root cause analyses and performance improvement initiatives.
• Provide oversight of Quality and Compliance staff, including developing annual performance reviews, if applicable.

Minimum Qualifications:

• Bachelor's Degree in Nursing or healthcare related field required. Master's Degree preferred. Five (5) years or more of progressive work experience that includes the development and implementation of programs for the elderly population, service operations, and staff development. Prior supervisory experience preferred.
• Minimum of one (1) year of documented experience working with a frail or elderly population.
• Comprehensive to expert proficiency with Microsoft product suite (MS Word, Excel, Power Point, etc.); basic knowledge and experience with electronic mail and calendaring system. Knowledge of systems necessary, experience preferred. Ability to type with speed and accuracy. Ability to use other software as required to perform the essential functions of the job.
• Ability to research, analyze and assimilate information from various on-site or virtual sources based on technical and experience based knowledge. Must exhibit critical thinking skills and possess the ability to prioritize workload.
• Position may require 10% travel within the Centers geographic region and to home office in Livonia, MI

Position Highlights and Benefits:

• Comprehensive benefit packages available, including 1st Day medical coverage, dental, vision, paid time off, 403B and educational assistance.
• Access to wages earned daily through Daily Pay.
• Ability to earn incentives through our Employee Referral program.
• Warm and supportive environment with a truly patient-centered focus.

• Comprehensive Orientation and professional development opportunities

Ministry/Facility Information
Trinity Health PACE programs offer continuous, quality care to the elderly, allowing them the independence of living at home. Seniors who qualify for nursing home care can receive comprehensive care from an interdisciplinary team of experts, all focused on improving participants' health.
At our centers, seniors receive clinical and rehabilitation therapy and build relationships with doctors, nurses and fellow participants - all under one roof. We serve together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities.
Our Commitment to Diversity and Inclusion
Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.