Employment Type:

Full time

Shift:

Day Shift

Description:

The primary purpose of your job position is to develop, implement, organize, and monitor the Quality Improvement Plan
for the PACE Organization (PO) and ensure overall CMS regulatory compliance. The Director, Quality Improvement and
Compliance, in collaboration with the Medical Director, is responsible for developing and implementing the annual QI plan,
including leading quality initiatives and projects. In addition, the Director ensures that data is collected from appropriate
sources, is examined and results are shared with all stakeholders.

1. Know, understand, incorporate, and demonstrate the Mission, Vision, Values and Guiding Behaviors of Trinity 
Health and Trinity Health PACE (TH PACE) in behaviors, practices, and decisions. 
2. Consistently demonstrate (leads by example) TH PACE Values to all internal and external customers 
(participants, visitors, volunteers, and colleagues.) Create and maintain an atmosphere of warmth, propagating a 
calm environment throughout the office. 
3. Execute assignments in a culture that is shared and collaborative across all divisions within TH PACE. 
4. Reflects the skills knowledge and abilities serving in the role of a leader. Define and share a strategy and vision; 
align resources toward achievement of organization results; grow and sustain the organization; identify, lead, and 
embrace change. 
5. Establish and/or maintain as a member of the leadership team a plan to achieve operating goals. 
6. Promote and maintain collaborative relationships with managers, peers, direct reports and customers by 
effectively fostering a team environment, building consensus and resolving conflicts.
7. Maintain department budget, place orders for equipment and supplies as necessary. Identify financial 
vulnerabilities and make cost reduction recommendations as needed. 
8. Evaluate, develop, mentor, coach, counsel and discipline department staff. Supports other personnel from other 
departments through coaching and mentoring to help achieve optimum standard of excellence. Addresses issues 
of concern through courageous conversation and notifies department manager of any interactions requiring 
attention. 
9. Maintains a working knowledge of applicable Federal, State, and local laws and regulations, TH PACE Corporate 
Integrity Program, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a 
manner that reflects honest, ethical and professional behavior. 
10. In light of a disaster will know your disaster recovery, crisis management and business continuity plans and act 
within your role that is developed within the business continuity plan. Which may include working at another 
location, remotely from home, and maintaining constant contact with key personnel. 
11. In conjunction with Medical Director, initiates, develops, and guides the implementation of the annual Quality 
Improvement plan. Compiles annual report and shares results with leadership, staff, contractors, administration, 
the Participant Advisory Committee (PAC), and Board of Directors. 
12. Assist with scheduling and coordination of the PACE Quality Committee in collaboration with Medical Director. 
 Duties include preparation of meeting agenda, preparation of minutes, and assistance with committee 
correspondence and presentation materials. 
13. Communicate the QI plan to members, staff, contractors, administration, Participant Advisory Committee (PAC), 
and the Board of Directors. 
14. Ensure compliance with CMS regulations. Has overall responsibility for the Medicare Part D fraud, waste and 
abuse Compliance Program. Assure annual review and approval of Compliance plan. Ensure that colleagues 
complete the activities and responsibilities identified in the Compliance program and those related to the HIPAA 
privacy rule. 
15. Manage preparation for CMS site visits, audits/inspections, and all subsequent follow up activities. 
16. Analyze risk management data and quality data in order to identify and control loss. 
17. Coordinates and maintains all activities pertaining to complaints, service delivery requests, and 
grievances/appeals, assures regulatory compliance and incident reporting including trend analysis for necessary 
action plans and quality improvement initiatives. 
18. Plan, develop, organize, implement, evaluate, coordinate, and direct PACE program’s infection control program 
in accordance with current rules, regulations, and guidelines that govern such requirements. 
19. Prepare monthly summaries of all participant/personnel infections, corrective action taken, and the results of the 
corrective action. 
20. Lead and facilitate Participan