PACE QUALITY AND COMPLIANCE DIRECTOR REPORTS TO: PACE Program Director and PACE Medical Director POSITION REQUIREMENTS: • Education equivalent to at least an Associate’s Degree form an accredited college with a degree in nursing, or related field or equivalent applicable education, experience, and/or training. Prefer Bachelor’s Degree in a health-related profession from an accredited institution or graduate from an accredited nursing program with experience in quality assurance. • Prior experience in applying quality assurance principles and participating in quality assurance programs. • Demonstrated clinical experience in a variety of healthcare settings. • Computer experience with proficiency in excel and PowerPoint. SUMMARY: The Quality and Compliance Director is responsible for the coordination and implementation of quality improvement activities; monitoring quality of services and care issues of Program for All-inclusive Care for the Elderly (PACE) participants; developing action plans for performance issues; communicating quality assurance activities and outcomes with staff; ensuring compliance with all federal and state regulations to maintain program excellence. DUTIES AND RESPONSIBILITIES: • Ensures staff and contracted personnel have knowledge of Quality Improvement and share data regarding QI activities with them. • Develops and implements a strategic comprehensive quality assurance and risk management program based on key PACE program processes/services to facilitate an efficient and cost-effective, low risk healthcare organization. • Produces data and reports on quality activities and performance and compliance. • Ensures Board of Director Members are aware and have knowledge of current QI and Compliance activities; Presents QI Annual Report to the Board of Directors and conducts Compliance training with them. • Assembles and analyzes data as information for Centers for Medicare & Medicaid Services (CMS)/National PACE Association (NPA)/Department of Medical Assistance Services (DMAS) reports as needed for the PACE Director. • Monitors AASC’s regulatory compliance and alerts PACE Director of possible deficits. • Schedules and conducts quarterly compliance meetings and monthly quality meetings and maintains meeting minutes. • Reviews and updates policies and procedures as needed. • Conducts annual participant satisfaction surveys. • Involves all staff in the QI program as owners of the program. • Uses standard methodology to document and assess QI activities. • Audits and/or maintains the Infection Control, Incident and Grievance Logs. • Audits the service delivery requests log. • Liaison with contracted vendor for the electronic medical record and trains and assists staff with usage. • Assists staff in process review, critical indicator selection, and threshold levels. • Involves PACE participants in the QI program. • Develops systematic reporting to all components of the PACE program system (Staff, Board of Directors, Participant Advisory Committee, and Contractors). • Performs chart audits to ensure completeness and accuracy. • Compiles and submits data to AASC, CMS, DMAS, NPA as required or requested. • Provides oversight of the PACE Emergency Safety Program and serves as PACE liaison to the AASC Safety Committee. • Liaison to Audit Teams from CMS and DMAS, preparing documents prior to audit, assisting during audit, and responding to Audit reviews and corrective action plans. KNOWLEDGE, SKILLS AND ABILITIES: • Knowledge of Quality Assurance principles and the ability to apply them to various situations. • Ability to set objectives and develop action plans. • Competent in identifying problems and developing effective solutions. • Strong critical thinking skills. • Orientation to detail and ability to see a broader picture. • Communicate effectively orally and in writing. • Possesses the skills to brief information to large groups. • Proficiency in data and word processing applications.