• Quality Manager - Full Time Days - Immanuel Pathways Southwest Iowa

    Job Locations US-IA-Council Bluffs
    Posted Date 5 months ago(5 months ago)
    Job ID
    # of Openings
    PACE Pathways
    Immanuel Pathways Southwest Iowa
  • Overview

    Develops, organizes and monitors a Quality Assessment and Performance Improvement (QAPI) plan for the Immanuel Pathways program. Responsible for developing the QAPI annual plan, and guiding the implementation of the plan. Ensures that data is collected from all appropriate sources; and the data is examined and the results are shared with all stakeholders. Oversees the process to evaluate and resolve medical and non-medical grievances by participants, their family members, or representatives. Acts as the Health Insurance Portability and Accountability Act (HIPAA) Privacy Compliance Officer for Immanuel Pathways. Ensures all Centers for Medicare and Medicaid Services (CMS) and State required activities are implemented and maintained. Supports and lives out Immanuel’s Mission and CHRIST Promises.


    Key Areas

    Key Responsibilities and Duties of the Job

    35% Quality Assurance

    • Develops, and guides the implementation of the annual QAPI plan.
    • Ensures staff integration into the QAPI process through Continuous Quality Improvement education and developing opportunities for input.
    • Analyzes risk management data, and QAPI activities data with the objective of identifying and controlling loss to protect the assets of the organization.
    • Facilitates the quality assurance/performance improvement process for various services areas within Immanuel Pathways.

    35% Participant


    • Conducts annual satisfaction surveys of the participants and caregivers of Immanuel Pathways and reports findings.
    • Reports data and information in the manner and at the time intervals specified by CMS and the State agency pertaining to participant care activities and outcomes.
    • Facilitates quality related communication between contract facilities and Interdisciplinary Team and employees.
    • Participates in orientation with contract facilities to ensure effective coordination of participant care, as needed provides scheduled on site inspection of contracted facilities to ensure quality care is provided and compliance with State and CMS regulations
    • Oversees the process to evaluate, and resolve medical and non-medical grievances by participants, and or their representatives, ensures information is reviewed for incorporating issues in development of Quality Improvement Initiatives and annual QAPI plan.
    • Attends the Participant Advisory Committee, assists in development of agendas, and acts as meeting facilitator.

    25% Compliance

    • In conjunction with the Executive Director, has overall responsibility for Immanuel Pathways’ Emergency/Disaster planning, training and implementation.
    • Ensures all Immanuel Pathways business relationships, and contracts are HIPAA compliant.
    • Implements Pathways policies and procedures related to Immanuel HIPAA policies.
    • Acts as Immanuel Pathways official HIPAA privacy/compliance officer under the guidance of the Immanuel Compliance Privacy Officer. Administers the process for receiving, documenting, tracking, investigating, and taking action on all complaints concerning Immanuel Pathways’ privacy policies and procedures in coordination and collaboration with other similar functions and, when necessary, legal counsel.
    • Participates and offers direction across PACE departments concerning questions and all activities interfacing with HIPAA rules and requirements.
    • Ensures that the following actions are completed in regard to HIPAA compliance:

    o   Providing initial training to new hires, and ongoing training to existing staff;

    o   Maintaining an accurate inventory of all individuals who have access to Immanuel Pathways’ confidential information and what the information was used for and/or to whom it was disclosed;

    o  Cooperating with the Officer for Civil Rights, other legal entities, and Pathways’ management in any compliance reviews or investigations;

    o   Disseminating the Privacy Notice required by the Privacy Rule;

    o   Conducting periodic privacy audits and taking remedial action, as necessary;

    o   Preventing retaliation against individuals who seek to enforce their own privacy rights or those of others.

    • Assumes overall accountability of the Medical Records and Compliance departments to ensure practices are in compliance with State Agencies and CMS.
    • Protects privacy and maintains confidentiality of all company procedures, results and information about employees, participants and families.

    5% Other

    • Performs relates duties as required or requested.
    • Ensures that the job responsibilities, authorities and accountability of all direct reports are defined and understood
    • Participates in continuing education classes and any required staff and training meetings.



    • Bachelors Degree in health related field or equivalent experience in health related field is required.
    • Equivalent years of experience may substitute for education requirement.


    • Four (4) years of demonstrated experience in QAPI activities in a health related work environment is required.
    • One (1) year experience working with frail or elderly population required.
    • One (1) year of management experience, preferably in a geriatric care setting is required.
    • Equivalent years of education may substitute for experience requirement.

     Other Requirements-

    • Must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact.
    • Must have a valid driver’s license, proof of insurance and have means of transportation.
    • Basic Life Support (BLS) Skills i.e. Health Care Level Cardiopulmonary resuscitation (CPR); Automated External Defibrillator (AED); First Aide (FA).

    KSA- Knowledge Skills and Abilities-

    • Knowledge of quality assurance concepts and policies.
    • Knowledge of basic statistical principles.
    • Skilled in written and verbal communication with specific ability to maintain accurate records.
    • Skilled in serving customers.
    • Skilled in data collection skills.
    • Skilled in establishing and maintaining effective working relationships with participants, co-workers, medical staff, and the public.
    • Skilled in identifying and recommending objective resolution to problems.
    • Ability to lead and supervise effectively.
    • Ability to be innovative, detailed-oriented and organized.
    • Ability to facilitate effective meetings
    • Ability to hold true to one’s integrity and practice discretion.
    • Ability to chart via Electronic Health Records
    • Proven experience and basic computer proficiency (internet, email, Microsoft Office)


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