Quality and Compliance Manager (RN Preferred)

POSITION SUMMARY: The Quality & Compliance Manager for the PACE (Program of All-Inclusive Care for the Elderly) program is responsible for planning, implementing, monitoring, and evaluating the Quality Assurance and Performance Improvement (QAPI) program. This position ensures compliance with federal, state, local regulations and PACE standards, focusing on improving participant outcomes, enhancing safety, and promoting continuous quality improvement across clinical, operational, and administrative domains.

MISSION: Improving lives, Optimizing wellness, Promoting independence

COMPETENCIES:

• Technical Expertise

• Problem Solving

• Teamwork

• Effective Communication

• Results Oriented

• Personal Credibility

• Quality Focus

• People Focus

• Flexibility

RESPONSIBILITIES AND DUTIES:

ESSENTIAL JOB FUNCTIONS:

• Develop, coordinate, and lead the QAPI program in accordance with CMS, state, and PACE-specific regulations.

• Collaborate with interdisciplinary team (IDT) members and department heads to identify performance gaps, analyze data, and implement quality improvement initiatives.

• Collect, analyze, and report quality and compliance metrics, including clinical outcomes, participant satisfaction, grievances, adverse events, utilization, and privacy incidents, to leadership and committees.

• Facilitate and document QAPI committee meetings, maintaining records of activities, goals, benchmarks, and follow-up actions.

• Monitor and manage the incident reporting process, including investigations, root cause analyses, and corrective actions.

• Lead quality improvement projects using PDSA, Lean, or Six Sigma, and build systems to monitor and improve care delivery, performance, and efficiency.

Compliance & Privacy:

• Support day-to-day operation of the compliance program, including the annual compliance risk assessment, auditing and monitoring work plan, and Compliance Committee.

• Develop, review, and maintain compliance and privacy policies and procedures on an established review cycle, and help departments keep their procedures current.

• Conduct regular audits, chart reviews, and risk assessments to ensure compliance with internal policies and external requirements.

• Intake, investigate, and resolve potential HIPAA privacy incidents, including breach risk assessments and notification to individuals, OCR, and the state as required; track and trend results.

• Investigate reports of potential noncompliance and fraud, waste, and abuse (FWA), and direct corrective action and retraining.

• Coordinate regulatory reporting and responses, including HPMS submissions, CMS and state incident reporting, and Complaints Tracking Module (CTM) resolution.

• Serve as one of the primary contacts for CMS and state audits and surveys, including audit universe preparation, responses, and corrective action plans.

• Monitor compliance of contracted providers and vendors, including exclusion screening (OIG/SAM).

Leadership & Collaboration:

• Develop and deliver staff training on quality improvement, regulatory compliance, HIPAA privacy, and FWA.

• Stay current on changes in healthcare, PACE, and privacy regulations; assess their impact and update policies and practices accordingly.

• Promote a culture of safety, accountability, ethics, and participant-centered care throughout the organization.

• Supervise, develop, and support the quality and compliance teams, including hiring, training, workload assignment, and performance management.

• Other duties as assigned by Vice President of Quality & Compliance.

ORGANIZATIONAL (CORE RATING FACTORS):

• Demonstrates support of the Company’s Mission, Vision and Core Values

• Provides Exceptional Customer Service

• Ensures discretion with confidential information in accordance with HIPAA guidelines

• Supports a collaborative work environment including courteous, helpful and professional behavior

• Embraces Organizational Excellence through practicing individual time management, efficiency and effectiveness and participating in continuous improvement efforts

• Adheres to and supports all Company policies and procedures

• Supports and practices safe work habits in accordance with policies and procedures

• Brings ideas, problems and concerns forward and participates in resolution and implementation

• Participates in and completes regulatory compliance trainings within the prescribed deadlines

• Attends required meetings

• Maintains skills and knowledge required including written and verbal communication, best practices for industry standards, and computer competency