Sr. Administrator Compliance, Privacy & Quality Improvement - PACE

Job Overview:

PACE Compliance, Privacy & Quality Improvement Sr. Administrator oversees the PACE of Cincinnati Compliance & Privacy ("C&P) and Quality Improvement (QI) Program. The role will report directly to the PACE Board of Directors ("the Board") and administratively to the PACE Senior Director. This role will maintain dotted-line reporting relationship with the PACE Medical Director and the TriHealth VP Chief Compliance, Privacy & Audit Officer. The Sr. Administrator shall not serve in operational areas. Oversight responsibilities include creation, annual review and update of the PACE QI plan, and development, implementation, and day-to-day operations of an effective C&P Program. This role will develop and implement of program-wide and PACE center-specific C&P and QI indicators, data management, program staff, C&P and QI education and training, preparation of quality reports, and coordination of program-wide process improvement or corrective action arising from monitoring, auditing and/or investigatory activities. The Sr. Administrator fully participates as a contributing member of the PACE of Cincinnati leadership team and identifies proper resources and strategies necessary to address risks and develops and manages annual C&P and QI budget.

Job Requirements:

Bachelor's Degree in a relevant field such as Health Care Administration, or Bachelor's of Science (Required)
Master's Degree in a relevant field (Preferred)
5 - 7 years Experience working in a healthcare compliance and/or quality improvement (Required)
Other CPHQ certification Preferred

Job Responsibilities:

Develops and implements the annual PACE of Cincinnati QI Plan and Quality indicators in collaboration with the PACE Medical Director. reviews, revises, and communicates the QI Plan no less than annually to participants, staff, contractors, leadership, and the Board. Ensures QI Plan and C&P Program are integrated into PACE Program operations developing action plans and monitoring schedules for required periodic initiatives; monitors implementation; and analyzes and reports adherence to leadership and the Board. Maintains up-to-date CMS and Ohio Department of Aging regulatory knowledge by keeping apprised of CMS guidance materials, develops, maintains and makes readily available C&P and Quality policies and procedures and educates PACE staff and agents/contractors appropriately. Oversees C&P Program and QI initiatives; assists leadership and the IDT with establishing QI performance improvement initiatives and C&P action plans and ensures appropriate and timely resolution. Leads CMS and other federal and State regulatory body’s audit, site visits and inspections preparation and response in accordance with TriHealth protocol.
Ensures that employees, contractors, patients, and/or their caregivers have the ability to report noncompliance anonymously in accordance with TriHealth Compliance & Privacy Program protocol. Prepares no less than quarterly QI Plan progress with quality indicator metrics and C&P Program updates to the Board to include results of auditing and monitoring activities and investigation of noncompliance in accordance with TriHealth Compliance & Privacy Program protocol. Ensures compliance with CMS & Ohio State PACE quality data, monitoring, and reporting, including quarterly reporting on PACE Health Plan Management System (HPMS) quality indicators.
Ensures response, investigation, and appropriate corrective action and resolution of any potential or actual instances of C&P noncompliance, to including reporting instances of fraud or other misconduct to the appropriate NBI MEDIC, CMS, and/or the State Administering Agency and other state-specific entities, in alignment with TriHealth Compliance & Privacy Program protocol. Conducts medical record chart reviews to monitor the quality of services provided to PACE participants and ensuring federal and state regulatory compliance; works closely with medical records staff to ensure all medical records documentation requirements are compliant and that medical records are retained in accordance with TriHealth policy. Oversees evaluating and resolving medical and non-medical grievances by participants and/or their representatives; ensures grievance information and trends are reviewed. Incorporates grievance trends in QI initiatives and the QI plan.
Coordinates internal and external appeal process; ensures information is reviewed to incorporate appeals trends in developing QI initiatives and the QI plan. Develops, implements and tracks completion of C&P & QI in-service training materials at onset of employment and annually thereafter to meet regulatory requirements and organizational needs; maintains documentation of C&P and QI program in accordance with TriHealth document retention and destruction policy. Conducts annual Risk Assessme