Vaya Health-posted 1 day ago
Full-time • Entry Level
Remote
501-1,000 employees

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.

  • 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.
  • 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.
  • 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.
  • 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.
  • 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 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.
  • Bachelor’s degree in a Human Service field (such as Psychology, Social Work, etc.) required.
  • Two years of experience in the field of mental health, intellectual and developmental disabilities, or substance use disorders is required.
  • CLEAR/NCIT Basic Certified Investigator (certification should be completed within the first 9 months of employment)
  • Master’s degree preferred.
  • Meeting the criteria of being a North Carolina Qualified professional in 10A NCAC 27G .0104 is preferred.
  • 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.
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