Job Description

Job Title: Senior Director of Quality, Education, & Compliance -- Senior Communities
Job ID: 723512
Status: Full-Time
Regular/Temporary: Regular
Shift: Day Job
Department: MGT Overhead SNF_ALF
Location: 3600 Forbes Ave, Pittsburgh PA 15213


UPMC Senior Communities has an exciting opportunity as we seek a Sr. Director of Quality, Education, and Compliance.  


The Sr. Director of Quality, Education, and Compliance reports to the COO for Senior Communities and works closely and collaborates with the CNO.  The Sr. Director is responsible for assuring clinical care standards and education within UPMC Senior Communities.  Skilled nursing and personal care facilities are maintained with the expectation of ensuring high standards of care while maintaining the facilities in compliance with regulatory agencies. 

The Sr. Director manages and coordinates SRC organization-wide effort to ensure quality care and regulatory compliance using a data-driven focus that sets priorities for education aligned to ongoing strategic goals, regulatory requirements and organizational initiatives. 

Monitors, analyzes and reports on a variety of data to assess the quality and appropriateness of care and facilities' performance and provides oversight and guidance for ongoing improvement efforts within the QAPI framework.

Collaborates with all facilities, departments, and Senior Leadership to mentor, educate and motivate staff surrounding data-driven performance improvement initiatives. Develops and fosters effective two-way communication of current trends, regulatory changes and QA/PI projects. 

Facilitates ongoing development and monitoring of capabilities to assure federal and state compliance throughout all facilities. Functions as the Privacy Officer for Senior Communities. The Sr. Director will have high visibility and interaction with the Chief Quality Officer.

  • Acts as a long term care privacy compliance and regulatory resource for UPMC.
  • Assures maintenance and development of clinical skills among the staff, through coordination of specific programs.
  • Coordinates the contracting and scheduling of student nurse rotations throughout the skilled nursing and personal care facilities.
  • Coordinates with the educational / training capabilities of the Aging Institute and other UPMC system resources, to optimize resources available for SRC staff development.
  • Creates an environment of quality assessment and performance improvement, regulatory compliance and clinical excellence. Communicates timely factual, objective, quantifiable Quality and regulatory compliance reports to SRC Senior Leadership. Tracks and communicates survey results, complaint investigations, scope and severity trends, and remedies to determine accurate decisions related to intervention strategies. Trends and analyzes quality outcomes and related system improvement opportunities for organizational quality assurance and performance improvement. Ensures identification of clinical data metrics for analysis of overall quality of care and Regulatory compliance.
  • Develops implements and monitors the QAPI process for the skilled nursing facilities.
  • Develops monitoring and reporting process for Quality Measures and CMS 5 Star performance.
  • Develops, implements, and monitors clinical care programs to meet the bundled payment process and improve clinical management through implementation of evidence-based best practices.
  • Develops, maintains and evaluates organizational systems that support attainment of regulatory compliance, with a focus on minimizing deficiencies and fostering an environment of Survey Readiness and achieve optimal 5 Star ratings.
  • Directs mock survey processes and related tool sets designed to identify issues and concerns.
  • Educates and evaluates staff compliance with policies and procedures related to nursing practice.
  • Ensures organizational compliance with CMS (and other regulatory agencies) regulations and reporting requirements.
  • Facilitates ongoing efforts to achieve and maintain optimum CMS Star rating.
  • Fosters facility preparation for CMS surveys with a focus on continual survey readiness. Leads & monitors mock survey functions for skilled nursing, assisted living and personal care facilities.
  • In conjunction with the Chief Quality Officer, the Sr. Director will collaborate with the Donald D. Wolff, Jr. Center for Quality, Safety, and Innovation.
  • Leads, coordinates, and facilitates the Nursing Education Council and Resident Support Coordinator Council. Leads and oversees wound care practice and wound care nursing.
  • Maintains active and current knowledge of CMS, DOH and DHS requirements for skilled nursing and assisted living facilities respectively.
  • Organizes, coordinates, and implements educational programs across the skilled nursing and personal care facilities within the SRC organization.
  • Oversees Case Mix Index and RUGS to assure revenue is aligned with clinical documentation and resident care needs. Collaborates on the design of the information technology infrastructure required to support QA/PI efforts.
  • Oversees and coordinates activities of the Staff Development Coordinators and Resident Support Coordinators.
  • Supports the UPMC SRC standards of practice in the implementation of education and clinical programs.
  • Uses regulatory development, facility-based findings, clinical program needs and feedback from facility operational leadership to identify educational needs whether facility specific or SRC-wide.


RN required Bachelors in Nursing required 

Masters in Nursing, Education, Gerontology or related Health Care Field required 

5 years of experience in acute care required 10 years of experience in Skilled and or Personal Care required 

Nursing Management experience in acute and or Long Term Care required Long term care Nursing Education, Quality and Compliance required

Licensure, Certifications, and Clearances:
CPR required based on AHA standards that include both a didactic and skills demonstration component within 30 days of hire

  • Act 34 Criminal Clearance
  • Basic Life Support
  • Basic Life Support
  • Cardio Pulmonary Resuscitation
  • Cardio Pulmonary Resuscitation
  • Older Adult Protective Services Act
  • Registered Nurse
  • Registered Nurse

UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $0 / hour

Union Position: No

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