Director, Quality & Compliance - PACE

Position Summary:

Under the direct supervision of Vice President of Senior Health Services, and technical supervision by the PACE Medical Director, the PACE Director of Quality and Compliance is responsible for developing, implementing and evaluating all activities of the San Diego PACE quality improvement and compliance programs. This includes overseeing the following activities: annual review and update of the quality improvement plan, development and implementation of program-wide and center-specific quality indicators, data management, education and training of program staff and contracted staff, preparation of routine and special reports, monitoring activities related to individuals, organizations and facilities that regulate or provide service directly or under contract to PACE and coordination of improvement efforts arising from monitoring activities. The Director of Quality and Compliance will administer the program by implementing systems and processes designed to ensure compliance with applicable laws, regulations and standards.

Essential Functions of the Job:

• Participates as a member of the San Diego PACE Management Team.
• Assures compliance with all State and Federal regulations regarding PACE services. Serves as the HIPAA Privacy Official and as such, provides leadership in complying with regulations related to patient privacy and protected health information or delegates this role and oversee. Ensures HIPAA training for all staff as required.
• Manages all aspects of QAPI program and other review processes to ensure quality participant care. Serves as the CMS and NPA representative for all quality and compliance related activities.
• Supervises the Quality Coordinator and Compliance Manager to ensure accurate and timely submission of regulatory requirements including HPMS/CMS reporting and other quality or compliance related duties.
• Works closely with the Medical Director, Program Director, and Interdisciplinary team (IDT) to identify standards, develop indicators, collect and analyze data; and plan corrective actions to improve performance.
• Oversee data management for QI activities including the coordination of collection, entry, analysis and assessment of data; utilizes findings and trends to improve policies and procedures.
• Compile statistical data and write narrative reports and presentations that summarize quality assurance findings and recommendations to PACE and San Diego PACE leadership.
• Attend and support the Quality Assurance Committee of the San Diego PACE Board of Directors on PACE-related matters. Alongside the PACE Medical Director, represents the PACE program within applicable San Diego PACE quality improvement committees and subcommittees.
• Provides oversight and direction for development, change control management, and implementation of PACE policies and procedures. Facilitates ad hoc workgroups for the development of policies, procedures, protocols, flowcharts and other job aids.
• Organizes and serves as project lead for audits by regulatory agencies. Develops tools to aid in preparation for audits; monitors progress of audit preparation; develops and implements corrective action plans (CAP); and ensures timely submission and communication with regulators agencies regarding the audits.
• In collaboration with SYH Compliance Program, designs, organizes, implements and oversees the PACE Compliance Program.  Monitors and measures compliance issues, CAPs, and the Fraud, Waste, and Abuse (FWA) program. Receives and documents reports of conflict of interest and non-compliance.
• Works with the appropriate departments and contracted providers to ensure licensing and certification requirements are kept up to date. Performs and oversee ongoing compliance monitoring activities, including periodical reviews of departments.
• Conduct ongoing analysis/assessment of operational performance for continuous process improvements, improved efficiency, and improved participant satisfaction.
• Oversees the San Diego PACE grievance and appeal process, including investigation of all quality reviews for potential quality of care concerns and quality of service and access issues, including collection and analysis of appropriate data. Ensures grievances/complaints are processed in accordance with applicable state and federal regulations, compliance standards, and policies and procedures.
• Responsible for ensuring timely reporting to regulatory bodies as required under state and federal laws and regulations, including unusual incidences and sentinel event reporting.
• Plan and oversee orientation and education for San Diego PACE staff and contractors. Ensures staff receives annual trainings including, but not limited to, infection control standards, OSHA, HIPAA, Fraud, Waste and Abuse
• Maintain and support a culture of compliance, ethics, and integrity.
• Maintain knowledge of policies and procedures and perform in accordance with applicable regulatory requirements, external laws, and accreditation standards as they relate to business & clinical risk management.
• Other projects and duties as assigned.

Additional Duties and Responsibilities

• Promotes and implements in-home electronic technology monitoring of PACE beneficiaries (telehealth, vital signs monitoring, remote patient monitoring, personal emergency response, fall detection, video surveillance of in-home caregivers and PACE participants).
• Medical Records oversight.
• Performs other duties as assigned.

Job Requirements

Education Required: 

• Bachelor’s degree in health-related field or equivalent relevant experience

Education Preferred:

• Master’s degree in nursing, public health, quality management, health care management or related field

Experience Required:

• 3 years of experience in healthcare quality improvement or healthcare compliance

Experience Preferred:

• Clinical background; experience with a PACE program or adult day health center setting

Certifications/Licenses Required:

• Valid driver’s license and reliable transportation; Proof of current vehicle insurance (if applicable)

Certifications/Licenses Preferred: 

• CPHQ certification,
• CHC or CHPC certification,  
• Clinical license (i.e. RN, LVN, BSN)

 Verbal and Written Skills Required to Perform the Job:

• Excellent interpersonal skills
• Excellent verbal and written communication skills 

Technical Knowledge and Skills Required to perform the Job:

• Must possess the skills necessary to provide care for geriatric patients
• Thrives in team environment
• Possess good organizational and supervisory skills
• Ability to effectively handle difficult and unusual interpersonal situations.
• Meet a standardized set of competencies for the specific position description established by SYH PACE and approved by CMS

 Equipment Used:

• Personal Computer, printer/fax, telephone, and other general office equipment

Working Conditions and Physical Requirements:

• Physical clearance for reaching, bending, stooping, crouching, kneeling and grasping
• Have full range of motion
• Ability to lift 50 lbs
• Need to lift and transfer participants
• T.B. clearance
• Must maintain current First Aid and CPR 

Universal Requirements 

Pre employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre employment PPDs. Compliance with all mandated vaccinations and all boosters is a term and condition of employment.