Director PACE Quality, Compliance, and Regulatory Affairs

Franciscan Health•Flexible Work Location, IN

3d•Hybrid

About The Position

The Director of Quality, Compliance & Regulatory Affairs leads the quality, compliance, and regulatory programs for the Franciscan Senior Health & Wellness PACE Program. As the designated Compliance Officer, this position ensures regulatory compliance, oversees quality and performance improvement initiatives, mitigates organizational risk, and promotes ethical and operational excellence. The Director collaborates with senior leadership, governing boards, and interdisciplinary teams to drive continuous improvement, maintain regulatory readiness, and support exceptional participant outcomes. Franciscan Health is a leading healthcare organization dedicated to providing exceptional patient care and promoting health and wellness in our community. Our mission is to ensure that every patient receives the highest quality of care through innovation, compassion, and excellence. With 11 ministries and access points across Indiana, Franciscan Health is one of the largest Catholic health care systems in the Midwest. Franciscan Health takes pride in hiring coworkers who provide compassionate, comprehensive care for our patients and the communities we serve.

Requirements

Bachelor's Degree Nursing/Patient Care/Healthcare Administration/Business Administration or related. - Required
Master's Degree Clinical Healthcare Field - Required -OR- In lieu of Masters degree, a Bachelors degree with an additional 5 years of relevant work experience -Required
3 years Quality/Compliance/Performance Improvement/Healthcare Management - Required
3 years Involvement in PACE program quality improvement, regulatory compliance, and CMS audit action planning and operational audit readiness - Required
3 years Experience developing multi-center compliance processes, documentation frameworks, and operational controls to support sustained regulatory readiness and risk mitigation - Required
Candidates without a clinical degree must possess a Bachelor's Degree and at least five (5) years of progressively responsible leadership experience in PACE program quality, compliance, and/or risk management.
Strong candidates will have experience integrating quality and compliance plans into operations with direct involvement in Interdisciplinary Team (IDT) decision support, serving in a lead role during PACE program audits, direct engagement with PACE program auditors and regulators, uploading files in HPMS, and event reporting. - Required.
Drivers License - upon hire - Required

Nice To Haves

Master's Degree Public Health, Healthcare Administration, Business Administration - Preferred
Juris Doctor - Preferred
2 years Experience with EPIC optimization and reporting - Preferred
2 years Experience creating and providing education to interdisciplinary health teams - Preferred

Responsibilities

Serve as the designated Compliance Officer for the PACE program, ensuring compliance with CMS, state, federal, HIPAA, and other regulatory requirements.
Lead the development, implementation, and oversight of the PACE Compliance Program, including audit readiness, regulatory monitoring, reporting, and corrective action planning.
Partner with federal and state regulators, governing boards, advisory councils, and organizational leadership on quality, compliance, risk, and regulatory matters.
Drive a culture of continuous quality improvement through oversight of performance improvement initiatives, outcomes measurement, risk mitigation, and operational excellence.
Lead regulatory audits, accreditation activities, compliance investigations, and root cause analyses to ensure ongoing organizational readiness.
Collaborate with operational, clinical, legal, risk, and compliance leaders to identify opportunities for process improvement, standardization, and regulatory compliance.
Oversee the Quality Improvement Program and ensure the development and execution of quality performance plans that support exceptional participant outcomes.
Provide strategic leadership for compliance, risk management, patient experience, and quality initiatives across multiple PACE centers.
Supervise and develop managers, educators, analysts, and other team members through coaching, performance management, and professional development.
Ensure policies, procedures, training programs, and competency initiatives remain aligned with evolving regulatory requirements and industry best practices.
Serve as a member of the PACE Senior Leadership Team, contributing to strategic planning, operational effectiveness, and achievement of organizational goals.
Represent the organization within professional associations, industry collaboratives, and PACE-focused networks to promote innovation, benchmarking, and best practices.