Quality Management Specialist (Remote NC)

Vaya Health

31d•Remote

About The Position

Under the supervision of the Customer Service Quality Manager, the Quality Management Specialist resolves member and provider grievances/complaints, processes incident reports, conducts Unlicensed Alternative Living Site Reviews, assists with Home and Community Based Service (HCBS) Assessments, assists with NC Treatment Outcomes and Program Performance System (NC TOPPS) Surveys, completes any needed health/safety site visits and completes provider investigations as requested for Quality Management. The position is responsible for resolving grievances and complaints received by Vaya Health by or on behalf of any member/recipient who is dissatisfied with a Vaya contracted provider, a Vaya employee, or any aspect of Vaya or it’s service delivery system. This is accomplished by processing complaint and grievance reports, coordinating resources, and communicating with all relevant parties throughout the grievance/complaint resolution process in a manner that is timely, thorough, fair, impartial, consistent, and compliant with applicable laws, rules and regulations. The position is responsible for ensuring all regulatory and accrediting guidelines/requirements are upheld throughout the resolution process. The position is responsible for reviewing incidents submitted into the Incident Response Improvement System (IRIS), Back-up staffing reports, and QM-11 reports submitted by providers in Vaya’s network. The position provides technical assistance and support to ensure all reporting requirements are met related to incidents and may include document preparation, records requests and meeting facilitation. In addition, the position monitors Provider sites within the Vaya Health provider network receiving reimbursement for service provision under Medicaid, the Innovations waiver, and state funding. The position monitors the remediation of areas of non-compliance to ensure adherence to all applicable rules, regulations, and best practice models and to ensure the health and safety of persons receiving services. This position will also provide back up oversight and suport to NC TOPPS and HCBS activities when the designated primary staff person is out on leave. The position will also complete any investigations or health/safety reviews as assigned. The individual must be knowledgeable about Vaya’s internal processes as well as providers, services, and stakeholders throughout the public behavioral health and intellectual/ developmental disabilities (IDD) system.

Requirements

High school diploma or GED required.
A minimum of two years of experience in quality management, data collection and analysis is required, preferably within a behavioral health organization
a minimum of two years of experience providing care and/or customer service in an acute care, physical health, physician and/or hospital setting.
Ability to develop practical, thorough, and creative solutions to complex problems
Ability to conduct data analysis and recognize trends is essential
Ability to effectively communicate trends within Vaya to address potentially serious issues is required
Ability to actively listen to grievances and complaints while maintaining a positive outlook and attitude with members, co-workers, and stakeholders
Ability to work remotely (from home) with little supervision and function as a self-starter
Flexible worker who readily accepts assigned tasks, manages unfamiliar situations, and searches for every opportunity to help the team
Excellent time management skills, including the ability to manage competing priorities and to complete tasks in a timely and accurate manner
Highly productive and motivated individual who takes pride in a job well done, demonstrates initiative and is committed to self-accountability
Strong attention to detail and extreme precision and accuracy
Ability to work collaboratively with individuals at all levels and with varying backgrounds both within and outside of Vaya and build strong working relationships
Strong organizational skills with the ability to multi-task
Ability to manage constant transformation and adapt to changing mandates from regulatory authorities as well as Vaya executive leadership
Ability to maintain the confidentiality of sensitive information in accordance with applicable laws, policies, rules and regulations
Ability to problem-solve and provide practical, thorough, and creative solutions to work tasks
Ability to learn, interpret independently, and apply a variety of complex policies and procedures
Good working knowledge and proficiency in Adobe and Microsoft Office 365 products (Word, Excel, Outlook, PowerPoint, Teams, Visio, SharePoint, etc.)
Thorough knowledge of how to use standard office equipment, including printers, scanners, and fax machines
Ability to work independently is essential
Ability to research multiple Electronic Records Systems -Ability to understand claims data
Ability to understand both physical and behavioral health diagnoses
Ability to synthesize information gathered in the grievance process to write a succinct resolution letter
Ability to interact with team while performing grievance resolution lead duties in a respectful manner
Ability to use critical thinking skills, work independently with little or no direction, demonstrate initiative, and function as a self-starter

Nice To Haves

Bachelor’s degree in a Human Services field preferred.
Meeting the requirements of being a Qualified Professional per 10A NCAC 27G .0104 preferred.
National Certified Investigator & Inspector Training and Certification is preferred.
Familiarity with Navex software products (PolicyTech, EthicsPoint) a plus
Knowledge of North Carolina’s public behavioral health and I/DD system, including Vaya providers, services, and stakeholders, preferred