Director of Quality, Safety, Compliance, and Risk

Grand Traverse Pavilions•Traverse City, MI

20h•Onsite

About The Position

As the Director of Quality, Safety, Compliance, and Risk, you will provide strategic leadership in the development, implementation, and oversight of Grand Traverse Pavilions' Quality Assurance and Performance Improvement (QAPI), compliance, risk management, and ethics programs. You will play a key role in fostering a culture of safety, ethical standards, and operational excellence, ensuring the well-being of residents and compliance with all federal and state regulations.

Requirements

Bachelor’s degree in Nursing
Valid RN license in the State of Michigan.
Experience in QAPI, risk management, safety, quality improvement, and compliance.
Knowledge of state (LARA) and federal (CMS) regulatory requirements for long-term care.
Strong leadership, communication, critical thinking, and analytical skills.
Ability to coach, educate, and influence staff at all organizational levels.

Nice To Haves

Master’s degree in a related field preferred.
Specialized training or experience in gerontology preferred.

Responsibilities

Lead and coordinate the facility’s QAPI Committee and monthly meetings.
Analyze departmental performance data to identify high-risk areas and implement performance improvement projects (PIPs).
Develop, monitor, and communicate key performance indicators (KPIs) and standardized processes across departments.
Conduct rounds and collaborate with teams to identify vulnerabilities and improvement opportunities.
Maintain comprehensive documentation of QAPI activities for regulatory review.
Ensure compliance with all federal, state, and local regulations, including Medicare, Medicaid, LARA, and CMS standards.
Integrate compliance into all aspects of operations and provide training to staff and volunteers.
Investigate compliance issues and coordinate corrective actions.
Participate in regulatory reporting and survey readiness, supporting facility-wide compliance initiatives.
Oversee adherence to the facility’s ethics and compliance program.
Implement internal reporting systems for suspected violations and ethical concerns.
Lead risk assessments, incident investigations, and post-fall huddles to minimize future hazards.
Collaborate with legal counsel, insurance providers, and leadership to resolve ethical and legal matters.
Ensure a safe environment for residents and staff, addressing hazards proactively.
Conduct safety inspections, oversee maintenance of patient care equipment, and enforce ergonomics and safety protocols.
Participate in committees related to safety, risk, falls prevention, and resident well-being.