Provider Quality Assurance Clinician (Remote)

LOCATION : Remote must live in / near any of Vaya’s catchment areas in North Carolina. Preference given to qualified candidates in the Burlington, Henderson or Charlotte area / region.

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, clinical requirements, best practices, provider’s contracts and federal / state rules and regulations.

Monitors provider agencies and independent practitioners within Vaya Health provider network receiving reimbursement for service provision under Medicaid, the Innovations waiver and state funding.

Working with a team of reviewers, using monitoring tools to identify instances of non-compliance that impact service / system quality and clinical requirements.

In addition, the Quality Assurance-Clinician will monitor the implementation of interventions aimed at addressing areas of non-compliance and clinical elements to ensure services are being delivered to consumers according to all applicable rules, regulations, clinical requirements and best practice models and to ensure the health and safety of members.

As a member of the review team, the Clinician will serve as the clinical expert for the team.

ESSENTIAL JOB FUNCTIONS

Network Performance Review and, Clinical Provider Monitoring Oversight :

Complete Routine Post-Payment reviews, Focused Monitoring, and investigations as a result of complaints, concerns, and incidents, or following directives of the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (MH / DD / SAS) or the Division of Health Benefits (DBH), to ensure quality of care of service for members.

The incumbent may function as the lead reviewer or may assist, and specific tasks involved include desk top reviews, on-site reviews, and staff and member interviews as part of the monitoring and investigation processes.

Provide technical assistance to providers during the course of reviews to assist providers in successful service delivery.

• 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.
• The Clinician will serve as a second reviewer and will assist unlicensed staff in reviewing clinical documentation.
• The Clinician will review documentation for clinical best practices to assist the reviewer in making a determination regarding clinical elements and compliance.
• The Clinician gives input regarding any best practice recommendations impacting member care for review findings / recommendations on clinical elements as applicable.
• The Clinician will assist in the review of any plans of correction submitted associated with review findings or recommendations on clinical elements.
• If the provider monitoring activity, focused monitoring or complaint investigation involves a Licensed Independent Practitioner (LIP), the Licensed Clinician will serve as a member of the review team.

Technical Assistance Referrals :

Provide technical assistance and address technical assistance referrals as assigned to assist Vaya Providers to be successful.

Health / Safety Checks :

Conduct Health and Safety checks as needed / assigned.

Additional tasks projects as needed / assigned.

KNOWLEDGE, SKILL & ABILITIES :

• Knowledge of state and federal rules, clinical 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.
• A high level of diplomacy and discretion is required to effectively negotiate and resolve issues.
• Exceptional interpersonal skills, and highly effective communication ability.
• 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.
• Ability to analyze and interpret policy and procedural guidelines.
• Excellent verbal and written skills.

QUALIFICATIONS & EDUCATION REQUIREMENTS

Master’s degree in a Human Service field (such as Psychology, Social Work, etc.) required. Two (2) years’ clinical experience in the field of mental health, intellectual and developmental disabilities, or substance use disorders.

Licensure / Certification Required :

Valid unencumbered North Carolina licensure or certification in profession (social work, counseling or psychology) is required.

Associate license is acceptable, full licensure is preferred. Acceptable licenses are Licensed Clinical Social Worker (LCSW), Licensed Clinical Social Worker Associate (LCSWA), Licensed Clinical Mental Health Counselor (LCMHC), Licensed Clinical Mental Health Counselor Associate (LCMHCA), Licensed Clinical Mental Health Counselor Supervisor (LCMHCS), Licensed Psychological Associate (LPA), Licensed Marriage and Family Therapist (LMFT), Licensed Marriage Family Therapist Associate (LMFTA), PhD, or PsyD.

Employee must maintain credentials including requirements for licensure (e.g. CEU’s).

CLEAR NCIT Basic Certified Investigator (CI) (should be obtained during first nine months of employment).

PHYSICAL REQUIREMENTS :

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists, and fingers.
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
• Mental concentration is required in all aspects of work.

RESIDENCY REQUIREMENT : Must live in / near any of Vaya’s catchment areas in North Carolina>

Preference given to qualified candidates in the Burlington, Henderson or Charlotte area / region. Must be willing to travel as needed for Health and Safety (H&S) reviews.

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