Clinical Quality Analyst (Full-time Remote, North Carolina Based)

Alliance Health•Fayetteville, NC

4d•$79,425 - $101,267•Remote

About The Position

The Clinical Quality Analyst manages the quality review process for care management programs. Incumbents conduct quality reviews of internal data and processes to identify trends/patterns that impact service/system quality and may require interventions. This position is fulltime remote. Selected candidate must reside in North Carolina. Some travel for onsite meetings to the Home office may be required.

Requirements

Graduation from an accredited school of Nursing with a Registered Nurse (RN) license and three (3) years of experience providing care management to individuals in the following populations; Traumatic Brain Injuries (TBI), Intellectual/Developmental Disabilities (I/DD), Mental Health/Substance Use Disorders (MH/SUD), Severe Mental Illness (SMI), or Physical Health (PH)
Master’s degree in Health, Psychology, Sociology, Social Work, or another relevant Human Services field from an accredited college/university with a North Carolina Clinical license (LCSW, LCMHC, LMFT, LPA) and three (3) years of experience providing care management to individuals in the following populations; Traumatic Brain Injuries (TBI), Intellectual/Developmental Disabilities (I/DD), Mental Health/Substance Use Disorders (MH/SUD), Severe Mental Illness (SMI), or Physical Health (PH)
Experience with Care plans, comprehensive assessments, care management interventions, and service engagement activities
Medicaid Managed Care
Integrated care (behavioral and physical health)
Knowledge of North Carolina State and Federal rules and requirements related to the service continuum in North Carolina
Knowledge of Tailored Plan, Integrated Care and Care Management processes and regulatory requirements
Knowledge of best and promising practices for behavioral & physical health and/or intellectual/developmental disabilities
Microsoft Excel, Word, PowerPoint, SPSS, and Survey Monkey (or other online survey tool)
Strong clinical skills
Problem solving skills
Interpersonal Skills
Strong Analytical skills
Problem solving and conflict resolution skills
Strong diplomacy skills and discretion
Highly effective communication skills
Ability to negotiate and resolve issues with minimal assistance
Current, active, unrestricted NC clinical license such as RN, LCSW, LMHC, or LMFT to practice as a health professional within the scope of licensure in the state of North Carolina.

Nice To Haves

Auditing Clinical documentation
Certified Care Manager (CCM)

Responsibilities

Analyze Care Management documentation and activities to ensure compliance
Review the quality-of-Care Management internal processes/plans and provider information, such as Person-Centered Plans or chart notes, for alignment with procedures and/or best practices
Audit Care Management clinical documentation, case interventions, and, if available, staff phone recordings to ensure alignment with program descriptions, workflows, internal policies, evidence based clinical guidelines, NCQA guidelines, CMS guidelines, and regulatory guidelines (when applicable)
Identify and escalate situations which may pose quality, compliance, and safety risks that may adversely affect business operation
Evaluate clinical appropriateness of decisions, recommendations, and actions within Care Management documentation
Interpret qualitative and quantitative information to appropriately document findings
Make recommendations for improvement related to any records reviewed and write reports of findings
Identify system and/or operational issues hindering the attainment of quality performance standards as defined by NCQA standards, applicable state and Federal laws and regulations
Generate monthly Care Management Quality reports on Staff performance to submit to Directors, Managers, and Supervisors
Provide written feedback to Directors, Managers and Supervisors concerning quality concerns pertaining to individual performance, compliance risks/trends, root cause analysis and any system or process improvements recommended
Evaluate knowledge gaps of the staff and collaborate with Care Management Leadership to coordinate learning and training opportunities with the Care Management Training team
Monitor training of staff for effectiveness and impact of outcomes from enhanced training