Quality Assurance Compliance Specialist - PSS

Multnomah County-posted 4 days ago

$43 - $53/Yr

Full-time • Mid Level

Portland, OR

1,001-5,000 employees

Resume

Match Score

Upload and Match ResumeTrack Jobs with Teal

THIS WORK MATTERS! This position is in the Quality Management (QM) and Compliance Program of the Behavioral Health Division (BHD). The QM/Compliance Program focuses on quality assurance and quality improvement processes, measurement of performance and quality indicators, and monitoring of compliance standards for contracted providers and county behavioral health (BH) services. This position works closely with programs in BHD that provide billable clinical services. This includes programs under the OAR 309-019 rule set.

Compliance Oversight and Clinical Standards Review
Provide subject matter expertise on compliance and regulatory requirements for BHD programs that provide clinical outpatient mental health and addiction services.
Be the clinical consultant for the Quality Management Compliance team on any matter that requires a QMHP or licenses staff lens, including, but not limited to critical incident, grievances, OAR interpretation and policy and procedures.
Provide expertise and technical assistance to drive initiatives, support programs in improving outcomes or services, and implement requirements.
Conduct work flow analysis to identify areas for improvement, simplify redundant processes, and address quality assurance/compliance requirements.
Identify problems and formulate solutions independently or through consensus with community providers, Oregon Health Authority (OHA) and the teams.
Collect and analyze information regarding the implementation of policy decisions, and analyze the effect of policy decisions upon service delivery and operations.
Monitor program compliance with OARs regarding provision of services, standards of care, and client health and safety.
Provide technical assistance when needed/requested by any of the teams.
Assist Quality Management and leadership teams with tracking Rule Advisory Committee meetings and provide engagement with rule changes, including in-person meetings, written feedback and comments and communication back to the team about how rule changes may impact work/workload as needed.
Independently conduct research around rules, regulations, requirements, best practices and evidence based practices.
Work closely with the BHD Billing team to review and resolve potential claims issues that could be related to fraud, waste and abuse. A general understanding of billing and claims rules are required for this position.
Complaints, Grievances and Incident Reviews
Apply quality assurance and quality improvement concepts and principles when evaluating incidents and grievances in BHD service programs and consult on incidents within BHD.
Analyze data for opportunities for improvement.
Conduct Peer Reviews and Root Cause Analysis (RCA) and formulate a critical Incident Review Report and other investigative reports, as needed.
Evaluate incidents to be sent through established Peer Review Processes and conduct Root Cause Analysis/Critical Incident Reviews.
Write Critical Incident Summaries and Investigative reports.
Monitor and report program violations.
Track corrective action plans and recommended action compliance based on RCA’s with BHD programs.
Maintain incident report and grievance folders and databases.
Provide Leadership Team incident report information for BHD reviews and trend analysis, quarterly.
Provide Director’s Office leadership regular reports on trends and systems issues from data collected through BHD incident reports and/or Peer Reviews and RCA processes.
Data Analysis is performed by this position with Incident Report Surveys presented to the State, County, and Providers Leadership Team.
Policies, Procedures and Contract Administration
Review and monitor annual/as-needed updates to Division policies and procedures.
Assure that policies and procedures are in compliance with any CMS, Federal, State rules and regulations and contract provisions.
Coordinate with Division Managers to address any programmatic changes to policies and procedures.
Advise senior management on policy and organizational issues with contract process and make recommendations for process improvement.
Identify problems and formulate solutions independently or through consensus with stakeholders; provide project management on inter-divisional contract projects; consult with programs in BHD to assist with their development and implementation of training for revised or new business systems or processes.
Contract citation and boilerplate content oversight over site for all contracts and amendments.
Review/revise boilerplates against guiding contracts (CFAC, CCO, and grants) and regulations annually.
Risk Assessments, Investigations and Audits
Develop, implement, and maintain BHD Compliance Plan, quality management plans and systems to ensure compliance and achieve program outcomes.
Conduct Risk Assessments and internal Audits of BHD programs when issues arise, or on a predetermined schedule per Compliance Plan.
Review mental health treatment records and conduct interviews.
Compile and analyze all investigative findings in order to reach a conclusion regarding allegations.
Write detailed investigative reports summarizing findings and supporting conclusions and recommendations for corrective action by mental health providers.
These reports range from the initial notification and brief description of allegations, through a comprehensive report of investigation and witness interviews needed to reach a conclusion and required actions.
Provide technical assistance when needed.
Monitor for compliance with any required action.
Participate in Behavioral Health compliance audits and quality assurance reviews.
Conduct investigations of fraud, waste and abuse allegations and code of conduct reports as needed.
Perform regular prospective and retrospective audits of Behavioral Health Direct Clinical Services claims.
Coordinate collection of overpayment when indicated.

Education/Certification: Must have a Masters degree and must meet the standards of Qualified Mental Health Professional - R (QMHP-R) with the Mental Health & Addiction Certification Board of Oregon (MHACBO). Please visit the MHACBO website to confirm your eligibility to apply
Experience: Five (5) years of increasingly responsible and major program development, policy analysis, or program compliance/monitoring and evaluation experience.
Knowledge, Skills and Abilities (KSA): Any working knowledge of contract compliance criteria and quality indicators .
Any experience in conducting audits or investigations, including data collection, analysis, recommendations for corrective action and compliance monitoring.
Experience with Medicaid billing, managed care systems, and/or health plans.
Other: This position requires a Background Investigation, which may include being fingerprinted.
Completion of Healthcare Basic Compliance Academy within 1st year in the position

Certified in Healthcare Compliance (CHC)
Lead with race through actions and advocacy with internal programs, with community partners and across departments throughout the county.
Demonstrate the ability to flex style when faced with myriad dimensions of culture in order to be effective across cultural context.
Respect and appreciation for ethnic and cultural diversity.
Ability to collaborate and build relationships to achieve positive work outcomes.
Ability to maintain a safe and healthful workplace.
High degree of resilience, is outcome driven and can thrive in an environment of rapid change while effectively managing pressure in an effective and professional manner.
Experience working in healthcare compliance
Experience working in the behavioral health field

Track Jobs with Teal

Job Search Resources

•

AI Resume Builder

•

Quality Assurance Resume Examples

•

Quality Assurance Cover Letter Examples

Quality Assurance Compliance Specialist - PSS

Job Search Resources

Tools

Career Hubs

Guides

Company