Director of Quality and Compliance

Trinity Health

20h

About The Position

The Director, Quality Improvement & Compliance is responsible for developing, implementing, organizing, and monitoring the Quality Improvement (QI) Plan for the PACE Organization (PO), ensuring full compliance with CMS regulatory requirements. In close partnership with the Medical Director, this leader oversees annual QI planning, drives quality initiatives, and ensures data-driven decision making by collecting, analyzing, and communicating key quality metrics to internal and external stakeholders.

Requirements

• Bachelor’s degree in Health Administration or related field required; Master’s degree preferred.
• Five (5) or more years of progressively responsible experience in healthcare delivery, program development, or service operations; experience with elderly populations preferred.
• At least one (1) year of experience working with frail or elderly individuals preferred.
• Prior supervisory experience preferred.
• Strong business acumen, decision‑making skills, conflict management, and adaptability to change.
• Excellent communication, presentation, and cross‑functional collaboration skills.
• Proficiency with Microsoft Office and related tools.
• High personal accountability and strategic planning capability.
• Ability to travel up to 10% within the region.

Nice To Haves

• Master’s degree

Responsibilities

• Develop and implement the annual Quality Improvement Plan in collaboration with the Medical Director, including compiling annual reports and presenting findings to leadership, staff, contractors, the Participant Advisory Committee (PAC), and the Board of Directors.
• Coordinate and support the PACE Quality Committee.
• Ensure compliance with CMS regulations, including oversight of the Medicare Part D fraud, waste, and abuse Compliance Program and HIPAA privacy requirements.
• Manage preparation for CMS site visits, audits, inspections, and all related follow‑up.
• Analyze risk management and quality data to identify issues and implement corrective actions.
• Oversee complaint, grievance, and incident reporting processes and conduct trend analysis to inform action plans.
• Lead infection control program planning and reporting, including monthly summaries and corrective action tracking.
• Facilitate Participant Satisfaction and HOS‑M surveys and analyze results.
• Ensure timely reporting to CMS, State agencies, and Trinity Health PACE.
• Monitor HPMS complaints and memorandums and coordinate required responses.
• Support process evaluations, root cause analyses, and performance improvement initiatives.
• Provide leadership and performance oversight for Quality and Compliance team members and collaborate with HIM, education, and clinical informatics teams.

Benefits

• Comprehensive benefits including 1st Day medical coverage, dental, vision, paid time off, 403B and educational assistance.
• Access to daily pay and employee referral incentives.
• Supportive environment with a patient-centered focus.
• Opportunities for professional development.
• Up to $4,000 in tuition reimbursement annually

What This Job Offers

• Job Type: Full-time
• Career Level: Director