Job Summary: Under the direction of the Quality and Compliance Manger, the Quality and Compliance Specialist is responsible for ensuring that the healthcare organization meets all regulatory and accreditation standards. This role involves developing, implementing, auditing and monitoring quality improvement initiatives, as well as ensuring compliance with local, state, and federal regulations. The specialist will work closely with clinical and administrative staff to promote a culture of safety, quality, and compliance. Quality and Compliance specialists play a vital role in assisting with the implementation of the Quality Assessment and Performance Improvement Plan (QAPI) for the St. Paul's PACE program. 

Duties and Responsibilities: 

• Assures full implementation of the annual QAPI Plan, performs contract facility 
  quality assurance audits to ensure quality participant care, collaborate with clinical staff to develop and implement evidence-based practices
•  Lead quality improvement initiatives aimed at enhancing patient care and safety and analyze data to identify trends and areas for improvement, and recommend corrective actions.
• Conduct regular audits and assessments to ensure compliance with healthcare 
  regulations, including HIPAA, OSHA, CMS, and specific state regulations.
•  Develop and implement policies and procedures to address compliance issues, with a focus on adherence to state-specific healthcare regulations.
• Monitor and ensure compliance with state licensing requirements, including timely renewals and adherence to operational standards mandated by the state.
• Conduct risk assessments to identify potential areas of non-compliance with state regulations and work with departments to develop mitigation strategies.
•  Provide training to staff on compliance and quality standards, including new 
  regulations and best practices.
• Develop educational materials and conduct workshops or seminars to promote a culture of quality and compliance.
• Ensures staff integration into the QAPI process through Continuous Quality Improvement education and developing opportunities for input.
• Manage the grievance and incident reporting process, including investigating and documenting case details, and ensuring appropriate corrective actions are taken.
• Maintain detailed records of compliance activities, audit results, and quality 
  improvement initiatives.
• Participates in quality assurance-related communication between contract facilities 
  and St. Paul's PACE Interdisciplinary Teams.
• Other duties as assigned 

Qualifications and Requirements: 

Education:

• Bachelor's degree in healthcare administration, Nursing, 
  or a related field.
• Certified Professional in Healthcare Quality (CPHQ) 
  or Certified in Healthcare Compliance (CHC) is preferred.

Experience:

• Must have a minimum of one year's experience working with 
  the frail or elderly.
• Proven experience in healthcare auditing or quality 
  assurance/improvement.
• One to three years or more years of relevant compliance experience and/or quality improvement is required; experience in healthcare or aging services compliance highly desirable. Experience in a clinical setting is a plus. 

Skills and Knowledge:

• Strong knowledge of healthcare regulations and accreditation standards.
• Excellent written and verbal communication, with specific ability to maintain 
  accurate records.
• Effective in project management/ LEAN Process Improvement
• Ability to manage multiple projects and meet deadlines
• Strong ability in auditing and monitoring
•  Effective data collection and analysis skills/knowledge of basic statistical principles
• Excellent analytical and problem-solving skills
• Strong communication and interpersonal skills
• Maintains the confidentiality of all company procedures, results, and 
  information about residents and participants, clients or families