Employment Type:

Shift:

Description:

Position Purpose:

The primary purpose of this position is to develop implement organize and monitor the Quality Improvement Plan for the PACE Organization (PO) and ensure overall CMS regulatory compliance. The Director Quality Improvement and Compliance in collaboration with the Medical Director is responsible for developing and implementing the annual QI plan including leading quality initiatives and addition the Director ensures that data is collected from appropriate sources is examined and results are shared with all stakeholders.

What you will do:

• Develop and implement the annual Quality Improvement (QI) Plan with the Medical Director

• In conjunction with Medical Director initiates develops and guides the implementation of the annual Quality Improvement plan. 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 Committee in collaboration with Medical Director.

• Communicate the QI 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 site visits audits/inspections and all subsequent follow up activities.

• Analyze risk management data and quality 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 PACE programs 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 the corrective action.

• Lead and facilitate Participant Satisfaction and HOS-M 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 participate 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 PACE program Quality and Compliance team members including developing annual performance reviews.

• Oversee and/or collaborate with HIM education and clinical informatics team members.

Minimum Qualifications:

• Must possess a comprehensive knowledge of healthcare delivery and management at a level as normally obtained through a bachelors degree (Masters Preferred) in Health Administration or other closely related field and approximately five (5) years or more of progressively more responsible related work experience that includes the development and implementation of programs for the elderly population service operations and staff development.

• A combination of education and experience may be acceptable.

• Minimum of one (1) year of documented experience working with a frail or elderly population preferred.

• Prior supervisory experience preferred

• Demonstrate strong business acumen decision-making skills manage conflict effectively and adapt to ongoing change.

• Maintain a customer-focused mindset with organizational agility and work independently with minimal supervision and sound judgment.

• Foster collaboration and productivity across cross-functional virtual teams and communicate clearly and effectively in both written and verbal formats.

• Engage diverse audiences with well-developed presentation skills.

• Proficient in Microsoft Office Suite; skilled in email and calendaring tools

• Exhibit high personal accountability and strategic planning abilities

• Position may require 10% travel within the Centers geographic region.

Position Highlights and Benefits:

• Comprehensive benefits including 1st Day medical coverage dental vision paid time off 403B and educational assistance.

• Access to daily pay and employee referral incentives.

• Supportive environment with a patient-centered focus.

• Opportunities for professional development.

• Up to $4000 in tuition reimbursement annually

Ministry/Facility Information

Trinity Health PACE of Montgomery County part of Trinity Health PACE provides high-quality care to seniors in the communities we serve. Our interdisciplinary team offers comprehensive services allowing seniors to remain independent at home.

If you are passionate about serving the elderly community and meet the qualifications we invite you to apply and become part of our dedicated team at Trinity Health PACE.

Submit your application today!!!

Our Commitment

Rooted in our Mission and Core Values we honor the dignity of every person and recognize the unique perspectives experiences and talents each colleague brings. By finding common ground and embracing our differences we grow stronger together and deliver more compassionate person-centered care. We are 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 veteran status or any other status protected by federal state or local law.