Trinity Health PACE · 10 hours ago
Director, Quality Improvement and Compliance
Alexandria, LA
Full-time
Onsite
Director/ExecutiveTrinity Health PACE is seeking a Quality Director to provide strategic leadership and operational oversight for their Performance Improvement, Quality, and Compliance programs. This role focuses on ensuring adherence to regulatory standards while promoting a culture of safety and continuous improvement for PACE participants.
Health CareMedicalNon ProfitOutpatient CareRehabilitationTherapeutics
Responsibilities
Lead the PACE Alexandria QAPI program, ensuring alignment with CMS standards and Trinity Health system expectations
Analyze data trends specific to our region (rural access barriers, caregiver strain, behavioral health needs, transportation delays, coordination challenges) and translate them into meaningful improvement initiatives
Facilitate monthly QI meetings with discipline leaders; prepare quality dashboards and reports for Trinity Health PACE leadership and governance committees
Lead RCA and FMEA processes related to participant safety events, transportation incidents, and care coordination gaps
Ensure QAPI documentation meets regulatory standards and reflects Alexandria‑specific improvement work
Maintain full readiness for CMS and state surveys, including unannounced visits
Conduct mock surveys with focus on interdisciplinary coordination, care planning, medication management, and home care documentation quality
Monitor changes in Louisiana regulations impacting PACE operations and ensure timely implementation
Oversee incident reporting and investigation processes, including participant falls, pressure injuries, behavioral events, transportation concerns, and community setting risks
Lead safety huddles and quality rounds in the center and collaborate with the Home Care Coordinator on trends in participants’ homes
Ensure timely and accurate reporting of mandatory events to the Louisiana Department of Health and CMS
Manage data integrity for quality indicators, participant experience surveys, utilization patterns, and IDT performance metrics
Produce reports that support strategic decision-making related to nursing home utilization, hospital readmissions, caregiver support, transportation reliability, and contracted provider performance
Partner with Trinity Health Corporate Quality and IT to optimize EMR reports and dashboards
Serve as a trusted partner to the Executive Director and leadership team in driving organizational priorities
Provide quality-related coaching and education across all disciplines, with special attention to clinical documentation, assessment timeliness, and coordination of care
Collaborate with partners such as SNFs, home care agencies, behavioral health providers, and acute care systems to improve transitions and service quality
Support development of a mission-driven culture of safety, respect, and continuous learning
Qualification
Required
Strategic leadership and operational oversight experience in Performance Improvement (PI), Quality, and Compliance programs
Knowledge of CMS, state, and Trinity Health regulatory standards
Experience in driving a culture of safety, continuous improvement, accountability, and exceptional participant outcomes
Ability to analyze data trends and translate them into meaningful improvement initiatives
Experience facilitating quality improvement meetings and preparing quality dashboards and reports
Knowledge of Root Cause Analysis (RCA) and Failure Mode and Effects Analysis (FMEA) processes
Experience maintaining readiness for CMS and state surveys, including conducting mock surveys
Ability to monitor changes in regulations impacting PACE operations
Experience overseeing incident reporting and investigation processes
Ability to lead safety huddles and quality rounds
Experience managing data integrity for quality indicators and producing strategic reports
Ability to partner with corporate quality and IT to optimize EMR reports and dashboards
Experience providing quality-related coaching and education across disciplines
Ability to collaborate with various healthcare partners to improve transitions and service quality
Company
Trinity Health PACE
Trinity Health PACE is a healthcare center that provides medical care, therapies, nutrition planning, and social services.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Lisa Lopez
Colleague Relations Partner
Nicole Sullivan
Senior Talent Acquisition Partner
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