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 Participant Satisfaction and HOS-M survey process and analyze data.
21. Ensure accurate and timely reporting to CMS, State, and all other Trinity Health PACE reporting requirements.
22. Daily monitoring of HPMS complaints and memorandums for quality and compliance updates. Coordinate any
necessary actions per HPMS memorandum guidance.
23. Prepare and submit monthly quality metrics reporting to Trinity Health PACE and participates in Trinity Health
PACE initiatives, meetings, and programs as required.
24. Assist staff in establishing process evaluation, including root cause analyses and performance improvement
initiatives.
25. Provide oversight of PACE program Quality and Compliance team members, including developing annual
performance reviews.
26. Oversee and/or collaborate with HIM, education, and clinical informatics team members.
27. May function as EMR super-user.
28. Maintain confidentiality of participant information.
29. Attend and participate in staff meetings, in-services, projects, and committees as assigned.
MINIMUM QUALIFICATIONS
1. Must possess a comprehensive knowledge of healthcare delivery and management at a level as normally obtained
through a Bachelor's Degree (Masters Preferred) in Health Administration or other closely related field and
approximately five (5) years or more of progressively more responsible related work experience that includes the
development and implementation of programs for the elderly population, service operations, and staff development.
A combination of education and experience may be acceptable.
2. Minimum of one (1) year of documented experience working with a frail or elderly population preferred.
3. Prior supervisory experience preferred.
4. Must be action-oriented, have business acumen, manage conflict well, be customer focused, have high decision
quality, flexibility to adapt to ongoing change and have organizational agility. Ability to work with minimal
supervision and exercise independent judgment.
5. Possess interpersonal skills to drive collaboration, commitment and productivity when working with crossfunctional teams, customers and end users. Must be comfortable functioning in a virtual, collaborative shared
leadership environment.
6. Demonstrates superior written and verbal communication and presentation skills appropriate for audience
comprehension. Well-developed communication skills, both written and oral, that may be used either in an on-site
or virtual environment is required. Able to communicate effectively with individuals and groups representing diverse perspectives.
7. Comprehensive to expert proficiency with Microsoft product suite (MS Word, Excel, Power Point, etc.); basic
knowledge and experience with electronic mail and calendaring system. Ability to type with speed and accuracy.
Ability to use other software as required to perform the essential functions of the job.
8. Possesses a high degree of personal accountability, responsibility and independent decision-making abilities with
the skills to plan, organize, develop, implement and interpret programs, goals, objectives, policies and procedures
of the organization in line with mission, vision, and philosophy of TH PACE.
9. Excellent organizational skills. Ability to perform multiple duties and functions related to daily operations and
maintain excellent customer service skills. Ability to perform frequent detailed tasks and provide immediate
service with frequent interruptions. Ability to change and be flexible with work priorities. Strong problem-solving
skills.
10. Ability to research, analyze and assimilate information from various on-site or virtual sources based on technical
and experience-based knowledge. Must exhibit critical thinking skills and possess the ability to prioritize
workload.
11. Position requires 10% travel within the Centers geographic region and to home office in Livonia, MI.
Our Commitment
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.