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Quality Assurance Specialist

Company: Vaya Health
Location: Marion
Posted on: August 7, 2022

Job Description:






LOCATION: Position is eligible for remote work however incumbent must be located within or near Vaya's catchment area. Irregular travel within the catchment area will be required for this role.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, 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. In addition, the Network Performance Specialist will monitor the implementation of interventions aimed at addressing areas of non-compliance, to ensure services are being delivered to consumers according to all applicable rules, regulations, and best practice models and to ensure the health and safety of members. Note: This position requires access to and use of confidential healthcare information or protected health information (PHI) as described in laws addressing patient confidentiality, including, but not limited to, the federal HIPAA law, the Confidentiality of Alcohol and Substance Abuse Patient Records law, 42 CFR Part 2, and various state laws. As such, the individual filling this position shall be required to be trained regarding such laws and shall be required to observe those laws in his/her capacity as an employee of Vaya Health. The individual filling this position shall also sign a confidentiality statement as an employee of Vaya Health. ESSENTIAL JOB FUNCTIONS:Serves as part of a monitoring team and will work as a part of that team to complete monitoring of network providers. Responsibilities include:* 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 whenever possible to assist Vaya Providers to be successful. * Conduct Health and Safety checks as needed/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. * Additional tasks projects as needed/assigned. QUALIFICATIONS & CREDENTIALING REQUIREMENTS: Must have a Bachelor's degree from four year college in Human Service field (such as Psychology, Social Work, etc.) is required, a Master's Degree is preferred with Two years' experience in the field of mental health, intellectual and developmental disabilities, or substance use disorders.
CERTIFICATIONS: CLEAR?NCIT Basic Certified Investigator (certification should be completed within the first 9 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.KNOWLEDGE OF JOB:* 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. * 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.

Keywords: Vaya Health, Asheville , Quality Assurance Specialist, Other , Marion, North Carolina

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