Provider Quality Assurance Specialist (Remote NC)

LOCATION: Remote - this is a home based, virtual position that operates Monday - Friday from 8:30am - 5:00pm EST. Candidate should live in North Carolina or within 40 miles of the North Carolina border. Must be willing to travel as needed for Health and Safety (H&S) reviews.

GENERAL STATEMENT OF JOB

This position is responsible for the assessment of services delivered to members to ensure services delivered are consistent with funding requirements, best practices, provider's contracts, and federal/state rules and regulations. The person in this position monitors provider agencies and independent practitioners within the Vaya Health provider network receiving reimbursement for service provision under Medicaid, the Innovations waiver, and state funding. This position works with a team of reviewers, using monitoring tools and processes to identify instances of non-compliance that impact service/system quality. Monitoring activities may include investigations, record reviews, health and safety checks, and the provision of technical assistance. Focused monitoring may also be conducted as a result of trends identified in data reports, complaints, concerns, and incidents, or as a result of a directive by the NC DHHS to ensure quality of care of service for members. In addition, the Quality Assurance Specialist will monitor the implementation of interventions aimed at addressing areas of non-compliance, to ensure services are being delivered to members according to all applicable rules, regulations, and best practice models, and to ensure the health and safety of members.

ESSENTIAL JOB FUNCTIONS

The incumbent in this position serves as part of a monitoring team and will work as a part of that team to complete monitoring of network providers. Responsibilities include:

Network Performance Review and, Clinical Provider Monitoring Oversight:

• Complete monitoring of behavioral health and physical health providers, including Post-Payment reviews, Block Grant Monitoring reviews, and Focused reviews based on performance report triggers as well as trends identified in data reporting, and other ad-hoc reviews as assigned. The incumbent may function as the lead reviewer or may assist, and specific tasks involved include desk top reviews, on-site reviews, reviews of member records, personnel files, provider policies, and staff and member interviews as part of the monitoring and investigation processes.
• Responsible for all correspondence, reports, monitoring reports, report of findings, and plan of correction activities for any review on which he or she serves as lead reviewer. Provide technical assistance to providers during the course of reviews to assist providers in successful service delivery.
• Complete and archive all correspondence, reports, monitoring reports, report of findings, and plan of correction activities for any review on which the incumbent serves as lead reviewer.
• Makes appropriate referrals to external entities as needed.
• Responsible for tracking the implementation of plans of correction to ensure out of compliance areas are addressed and mitigated within required timeframes.

Technical Assistance Referrals:

• Support Network Providers by providing technical assistance and responding to technical assistance referrals as assigned.
• Complete all associated activities to document and track technical assistance provided.

Health/Safety Checks:

• Conduct announced or unannounced Health and Safety checks as needed and/or assigned to assess quality of care and ensure member Health and Safety.

Other duties as assigned.

KNOWLEDGE, SKILLS, & ABILITIES

Success in this position requires exceptional interpersonal skills, and highly effective communication ability. A high level of diplomacy and discretion is required to effectively negotiate and resolve issues. In addition, the person in this position must have:

• Knowledge of state and federal rules, requirements and practices related to the service continuum in North Carolina.
• Knowledge of policy and procedure is essential related to monitoring plans of correction and resolution.
• Ability to analyze and interpret policy and procedural guidelines.
• Problem solving and conflict resolution skills are essential.
• Excellent computer skills; proficiency in Microsoft Office Suite; and experience creating documents, forms, and graphs.
• Skilled in organizing workflow and strong detail orientation.
• Excellent verbal and written skills.

EDUCATION & EXPERIENCE REQUIREMENTS

Bachelor's degree in a Human Service field (such as Psychology, Social Work, etc.) required. Master's degree preferred. Two years of experience in the field of mental health, intellectual and developmental disabilities, or substance use disorders is required.

Meeting the criteria of being a North Carolina Qualified professional in 10A NCAC 27G .0104 is preferred.

Licensure/Certification Required:

• CLEAR/NCIT Basic Certified Investigator (certification should be completed within the first 9 months of employment)

Preferred work experience:

• Three or more years of experience in the field of mental health, intellectual and developmental disabilities, or substance use disorders is preferred.
• Meeting the criteria of being a North Carolina Qualified professional in 10A NCAC 27G .0104 is preferred.

PHYSICAL REQUIREMENTS

RESIDENCY REQUIREMENT: The person in this position should live in North Carolina or within 40 miles of the North Carolina border.

SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.

DEADLINE FOR APPLICATION: Open until filled

APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.

Vaya Health is an equal opportunity employer.