Director of Program Integrity

Primary Purpose

• Quality Assurance and Program Integrity
• Compliance with regulations
• Oversight of corporate compliance plan
• Health Management Plan Service Delivery & Effectuation

Duties and Responsibilities

• Develops, implements, and maintains Senior Care Partners PACE corporate quality plan, policies, standards, and procedures.
• Responsible for execution of corporate quality plan and oversight of quality team.
• Oversees the process to evaluate and resolve medical and non-medical appeals by participants and/or their representatives.
• Develops, implements, and maintains Senior Care Partners PACE corporate compliance plan, policies, standards, and procedures.
• Responsible for the execution of the corporate compliance plan.
• Conducts annual effectiveness evaluations of the Senior Care Partners PACE compliance program with respect to related State and Federal regulations and requirements with recommendations for system improvements.
• Develops, implements, and maintains Senior Care Partners PACE Emergency Preparedness Plan, policies, standards, and procedures.
• Assures continuing analyses, technical expertise, and knowledge transmission of corporate compliance requirements in keeping with evolving federal PACE and Medicare Part D requirements and MDHHS contractual obligations and standards.
• Serves as the administration for health plan functions.
• Provides data tracking and reporting for CMS risk adjustment reporting, encounter reporting, and PACE industry benchmarking.
• Serves as the organization's Compliance and Privacy Officer Responsible for Health Information Management teams to ensure the electronic health record supports participant care and relevant regulations.
• Proactively identifies risk points for the organization and informs the CEO and/or Directors and the Board of Directors as needed.
• Coordinates audits by CMS and MDHHS
• Establishes systems and processes to routinely audit MER documentation to verify documentation practices align with established standards and regulatory requirements.
• Reviews the integrity of the IDT service authorization process and monitors internal and external service utilization to verify IDT approval and compliance with Service Delivery Request policies.
• Establishes systems and processes to routinely perform internal risk assessments, identify noncompliance, and oversee corrective action plans to remediate risk and prevent future noncompliance.
• Responsible for overseeing provider compliance with state and federal regulatory and statutory requirements and Senior Care Partners PACE policies and procedures.
• Serves as a role model and leader within the organization. Builds relationships with all staff at all centers.
• Must care, support, and collaborate with everyone involved in participant's care including the participant’s family using the patient-family centered care approach.
• Participates in Board of Directors meetings as needed

Supervisory Responsibilities

• This position has supervisory responsibilities for the compliance department staff and Quality Improvement staff.

Qualifications

• Bachelor’s degree in nursing, Healthcare Administration, or applicable field required.
• At least 5 years of experience in a leadership role focused on program integrity, compliance, or ethics within a healthcare or similar setting.
• In-depth knowledge of healthcare regulations, laws, and compliance requirements. Strong analytical and problem-solving skills.
• Excellent communication and interpersonal skills.
• Proven leadership abilities and the capacity to inspire and lead a team.
• Ability to work collaboratively and effectively with diverse stakeholders.
• Effective utilization of electronic communication and data analytical software to include Microsoft Office Suite - Word, Excel, Outlook, and PowerPoint.
• Use data to inform change.
• Experience with HRO and/or LEAN principles preferred.
• Use rapid cycle change, lean, and other proven strategies to drive effective change.
• Minimum of one year of experience working with the frail, elderly, or long-term care population.
• Minimum Working Requirements Must have reliable transportation, current valid Michigan driver’s license and car insurance. Must be 18 years of age or older. Must be fully vaccinated, or willing to be fully vaccinated against the following communicable diseases: Influenza, MMR, Varicella, Tdap/Td, Covid-19 and Hepatitis B.

If interested, please apply here.