Quality Assurance Manager (53896)

Redwood Coast PACE with Humboldt Senior Resource Center is looking for a full-time Quality Assurance Manager. Redwood Coast PACE — a Program of All-inclusive Care for the Elderly — is a comprehensive health plan for older adults who wish to remain living in their home and community. We provide medical, social, nutritional, rehabilitation, and support services for eligible adults. At Redwood Coast PACE, the goal is to help people stay as healthy and independent as possible. Because their health is monitored on a regular basis, many PACE participants report fewer health crises and better overall health.

The schedule for this position is Monday through Friday, 8 am to 5 pm.

JOB SUMMARY: Under the direction of the Director of Redwood Coast PACE, develops, implements, and evaluates all activities of the Quality Improvement Plan (QIP). Acts as the compliance/HIPAA officer for Medicare Part D Fraud, Waste, and Abuse.

ESSENTIAL DUTIES & RESPONSIBILITIES:

1. Demonstrates respect for and promotes participant rights including dignity, self-determination, access to care, confidentiality, and independence.
2. Maintains confidentiality of all records and information.
3. Serves as a liaison among individual program disciplines, contracted hospitals, and community service providers on issues related to quality of care.
4. Coordinates with members of the Interdisciplinary Team (IDT) regarding quality of care and service delivery.
5. Designs, organizes, and implements the Redwood Coast PACE Compliance Program. Monitors and measures compliance issues, including conflicts of interest. Receives and documents reports of conflicts of interest and non-compliance.
6. In conjunction with the Director of Redwood Coast PACE, Assistant Director, and Center Managers, prepares and participates in Centers for Medicare & Medicaid Services (CMS) and Department of Health Care Services (DHCS) audits and develops corrective action plans.
7. Under the direction of the Director of Redwood Coast PACE, develops and updates policies and procedures.
8. Works with the Director of Redwood Coast PACE to ensure all program contractors and service providers are fully licensed and compliant with provider agreements, quality assurance, and participant rights policies and procedures.
9. Develops and monitors policies and procedures for quality oversight of contract services and provides related documents and information to contractors. Works closely with the Director of Redwood Coast PACE to receive, document, and resolve contractor incidents.
10. Conducts on-site review of contract organizations with delegated quality assurance programs, including medical groups, hospitals, and skilled nursing facilities. Coordinates credentialing of program health professionals.
11. Oversees the annual QIP update. Works closely with the Director of Redwood Coast PACE, Assistant Director, Center Managers, and IDT to identify standards, develop indictors, collects and analyzes data, and provides corrective action to improve performance.
12. Produces and interprets reports used in the QIP which may include reviews of medical records utilizing approved criteria. Prepares documents, reports, and/or medical record data for review by the Medical Advisory Committee (MAC), Quality Improvement Committee (QIC), and related subcommittees.
13. Coordinates quality assurance activities related to new enrollees as well as voluntary and involuntary dis-enrollment.
14. Evaluates and works to receive, document, and resolve medical and non-medical grievances and appeals by participants and/or their representatives (e.g. reports of participant rights violations, grievances, appeals, and other issues related to services and quality of care). Ensures information is reviewed for incorporating issues in development of the QIP.
15. Conducts focused and ad hoc quality studies and analysis shows. Identifies opportunities for improvement and facilitates annual Continuous Quality Improvement (CQI) projects.
16. Facilitates participant and caregiver satisfaction surveys every six (6) months as part of the Redwood Coast PACE QIP. Provides reports to the leadership team, QIC Committee, and Participant Advisory Committee (PAC).
17. Educates and assists Redwood Coast PACE employees regarding QIP initiatives. Collects aggregate information on participant care that is provided to the Medical Director/Primary Care Physician and MAC.
18. Ensures implementation of the Infection and Exposure Control plan, working collaboratively with Redwood Coast PACE medical professionals to ensure compliance of the plan.
19. Completes CMS quarterly reporting and participates in quarterly calls.
20. Completes bi-annual reporting for National PACE Association (NPA) and CalPACE.
21. Complies with safety policies and procedures, identifying and immediately reporting any potential or actual unsafe acts or conditions to the Center Manager. Takes necessary measures to ensure a safe environment for others.
22. Serves as the Redwood Coast PACE Health Insurance Portability and Accountability Act (HIPAA) privacy officer under the direction of the MAC.
23. Supervises Medical Records Coordinator. Oversees requests for protected health information and ensures all requests for participant information have been approved by the participant and are HIPAA compliant.
24. Participates as a member of the Redwood Coast PACE leadership team and serves as the Redwood Coast PACE compliance officer.
25. Represents Redwood Coast PACE on the Humboldt Senior Resource Center’s agency Safety Committee and completes bi-annual Hazard Assessments.
26. Ensures that Redwood Coast PACE Incident Reports and fall assessments are completed and tracked for trends and compliance.
27. Participates in orientation with employees and contractors to ensure effective coordination of participant care.
28. Effectively collaborates with employees and contractors to meet Redwood Coast PACE goals and further success.
29. Complies with all policy and procedures of Redwood Coast PACE.
30. Acts in a manner consistent with agency values.
31. Other duties as assigned.