Quality and Compliance Manager

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

Qualifications

QUALIFICATIONS AND REQUIREMENTS:

Education & Experience:

• Bachelor’s degree in nursing, Public Health, Healthcare Administration, or related field required.
• Minimum of 5 years of experience in healthcare quality and/or compliance, preferably within a PACE, long-term care, or senior services setting.
• Strong knowledge of CMS PACE regulations (42 CFR Part 460), QAPI requirements, and HIPAA Privacy and Breach Notification Rules.
• At least 2 years of supervisory or team leadership experience required.

Certifications:

• CPHQ (Certified Professional in Healthcare Quality), CHC (Certified in Healthcare Compliance), or CHPC (Certified in Healthcare Privacy Compliance) preferred.
• Lean Six Sigma certification preferred.
• RN license preferred but not required.

Skills & Competencies:

• Data analysis and reporting, including EHRs, quality reporting tools, and data visualization.
• Quality improvement methods (PDSA, Lean, Six Sigma) and root cause analysis.
• Investigation and documentation skills, with sound judgment and discretion with sensitive information.
• Project management and the ability to meet multiple regulatory deadlines.
• Strong written and verbal communication with staff, leadership, regulators, and participants.
• Integrity, ethical judgment, and the ability to work independently and collaboratively.