Quality Improvement Manager

Compliance & Regulatory Oversight

• Support and operationalize the PACE compliance program in alignment with CMS PACE regulations (42 CFR Part 460)
• Responsible for maintaining up-to-date CMS and ODA regulatory knowledge and educating PACE staff appropriately.
• Responsible for compliance with CMS PACE and State PACE quality data monitoring and reporting including quarterly reporting on PACE Health Plan Management System (HPMS) quality indicators.
• Conduct internal audits (clinical documentation service delivery grievances incident reporting)
• Prepare for and support external audits and site visits (e.g. CMS/DHCS audits from engagement letter to CAP acceptance)
• Monitor and ensure compliance with federal and state requirements (CMS DHCS Medi-Cal)
• Track investigate and report compliance concerns incidents and corrective actions
• Maintain policies and procedures to ensure regulatory alignment
• Work closely with medical records staff to conduct medical record chart reviews to monitor the quality of services provided to PACE participants and to ensure all medical records documentation requirements are compliant with federal and state regulations and that medical records are retained for 10 years

Quality Assurance and Program Improvement (QAPI)

• Collaborates with the Medical Director on developing the annual QAPI Plan
• Reviews revises and communicates the QI Plan to participants staff contractors leadership and the Governing Body.
• Lead and coordinate QAPI initiatives across clinical and operational domains
• Develop and monitor key performance indicators (KPIs) such as: Hospitalizations ED utilization falls pressure injuries medication management and polypharmacy timeliness of care (urgent vs routine visits)
• Facilitates QI meetings to ensure integration of the QI Plan into PACE program operations; develops action plans and monitoring schedules for required periodic quality activities; monitors implementation; analyzes and reports on adherence.
• Prepare and present quality data to medical and operations leadership
• Facilitate root cause analyses (RCAs) and performance improvement projects (PIPs)
• Oversees evaluating and resolving medical and non-medical grievances by participants and/or their representatives; ensures information is reviewed to incorporate grievance trends in developing QAPI plan
• Responsible for coordinating the internal and external appeal process; ensures information is reviewed to incorporate appeals trends in developing Quality Improvement initiatives and the QI plan.
• Participates in preparing and administering annual satisfaction surveys of the participants and caregivers and reports findings.
• Participates in Infection Control activities.
• Support a culture of continuous improvement and patient safety

Education & Training

• Educate staff on compliance requirements documentation standards and quality initiatives
• Integrates QI information into orientation and training for new staff.
• Facilitates quality assurance communication between contract facilities and the IDT; participates in orientation with contract facilities to ensure the effective coordination and quality of participants care.
• Develops and implements QI staff development and in-service training materials to meet regulatory requirements and organizational needs; maintains documentation of QI staff development and in-service training in compliance with regulatory requirements and organizational standards.
• Support onboarding and ongoing training related to regulatory readiness and quality metrics
• Provide feedback to IDT members to improve documentation and care processes

• Relevant Bachelors degree such as Health Care Administration or Bachelors in Science.
• Minimum two years experience working in healthcare compliance and quality improvement. Clinical background preferred.
• Familiarity with QAPI programs and performance improvement methodologies (e.g. PDSA cycles Lean)
• Knowledge of regulatory frameworks (CMS Medi-Cal/DHCS)
• Strong analytical organizational and communication skills

• Experience in PACE or other capitated/managed care models
• Clinical background (RN BSN MSN) preferred.
• Experience preparing for or participating in regulatory audits
• Proficiency with EHRs (e.g. Epic) and data tools (Excel dashboards)
• Certification in healthcare quality (e.g. CPHQ) or compliance.