Quality Management Specialist (Remote NC) at Vaya Health

, North Carolina, United States -

Full Time

Start Date

Immediate

Expiry Date

09 Jun, 26

Salary

60193.06

Posted On

11 Mar, 26

Experience

0 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Grievance Resolution, Complaint Resolution, Incident Report Review, Health And Safety Reviews, Site Reviews, Investigations, Data Analysis, Technical Assistance, Record Review, Communication, Time Management, Organizational Skills, Problem Solving, Policy Interpretation, Collaboration, Attention To Detail

Industry

Hospitals and Health Care

Description

LOCATION: Remote – prefer incumbent live in North Carolina or within 40 miles of the NC border. This position requires travel as needed. GENERAL STATEMENT OF JOB 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 its 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 support 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. ESSENTIAL JOB FUNCTIONS Grievance, Complaint, Incident, Health & Safety Response and Reviews: This position will support Provider Quality Operations and Customer Service Quality. Support of these operations may be accomplished through various activities like those listed below, and although day to day work may include activities related to these items this is not a limited list. At the manager’s and director’s discretion activities may be divided among the incumbents which may lead to some incumbents completing some of these tasks more than others, but all incumbents must be cross trained and able to complete all items. Activities may include, but are not limited to: Member/Recipient/Provider Grievance/Complaint Resolution The incumbent is responsible for managing assigned complaints and grievances by ensuring the concern of the individual is properly acknowledged, documented, and addressed to work toward informal resolution by: * Answering questions from members, recipients, stakeholders, or others about the complaint/grievance process * Timely resolving complaints and grievances through the following activities: * Phone interviews with the filer and person(s) who have a legitimate role in the issue to be resolved (i.e. staff, legal guardians, providers, care managers, etc.). to obtain additional information or clarification; * Consultation with Vaya staff, licensed clinicians, and subject matter experts * Provider record/information request and record review * Maintain timely responses to inquiries regarding grievances and complaints * Provide recommendations and direction to both service providers and members in an attempt to eliminate repeated grievances of a similar nature * Provide feedback to providers regarding written responses to grievances and complaints * Recognize grievances and complaints that include health and safety issues that need to be immediately addressed by accurately depicting the situation in a case staffing to the CMO * Recognize health and safety issues may require investigation including; but not limited to, an on-site review to ensure any Vaya members in service locations are safe. Incident Report Review, Tracking and Technical Assistance The incumbent reviews incident reports from all Vaya provider agencies within the catchment area and incident reports from provider agencies that have Vaya enrollees who receive services outside Vaya’s catchment area. IRIS is a mandated electronic system for provider and LME/MCO to document the occurrence of Level II and III incidents. Incident review and response includes the following: * Ensure the incident report is complete and has accurate information, request any additional or missing information * Evaluate the cause/prevention section and provide technical assistance to the provider when standards for future prevention are not met * Evaluate the likeliness that the incident will be in the media and alert the CMO Tracking and trending of incidents; report any trends of concern to CIRC. In addition, this position is also responsible for completing the following incident report related activities: * Track and trend back-up staffing reports and compile and prepare data for quarterly reporting as needed * Track and trend QM-11 (level 1 incident) reports Health/Safety Reviews including any Site Review * Monitoring activities for AFL Site Reviews * Use a standardized tool (checklist) for initial AFL site reviews and annually thereafter * Ensure the site has met HCBS standards and approval * Medication review * Review the site for Health and Safety concerns that are specific to the member/recipient * Inform/educate the Provider about Vaya procedures for monitoring of existing and new AFL homes * Completion and delivery of all written findings to the Provider, and follow up on all deficiencies * Assess sites for health/safety when required from grievances/complaints as part of investigations Investigations: * Assisting with On site investigations completed by any Quality Management Team * Complete assigned investigations related to grievances/complaints or health/safety requests * Complete Report of Findings * Complete Plans of Correction for Out of Compliance noted in Report of Findings * Communicate with Providers related to investigation and outcomes * Communicate with grievant/complainant/stakeholders as required for investigations Additional Tasks: * Provide Backup to HCBS Provider Self-Assessment Review and Approval Process including: * Upon submission, process and ensure Provider Self-Assessments are complete, accurate and meet criteria for HCBS standards, provide information and technical assistance to providers in response to incorrect or missing information. * Provide Back up to NC TOPPS Activities to comply with state requirements including: * Respond to NC TOPPS email inquiries, answer questions from providers or provider staff about NC TOPPS requirements, provide technical assistance to providers or provider staff on NC TOPPS. KNOWLEDGE OF JOB * 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.) * Familiarity with Navex software products (PolicyTech, EthicsPoint) a plus * Thorough knowledge of how to use standard office equipment, including printers, scanners, and fax machines * Knowledge of North Carolina’s public behavioral health and I/DD system, including Vaya providers, services, and stakeholders, preferred * 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 * Ability to develop practical, thorough, and creative solutions to complex problems EDUCATION & EXPERIENCE REQUIREMENTS High school diploma or GED required. Bachelor’s degree in a Human Services field preferred. Must have * A minimum of two years of experience in quality management, data collection and analysis is required, preferably within a behavioral health organization OR * a minimum of two years of experience providing care and/or customer service in an acute care, physical health, physician and/or hospital setting. The Tailored Plan does not require NC Residency for this role; however, it is the preference of Vaya and the Quality Management department that incumbents of this role fall within the guidelines of NC Residency Requirement per the Tailored Plan and reside in North Carolina or resides within 40 miles of the North Carolina border. Preferred work experience: * Meeting the requirements of being a Qualified Professional per 10A NCAC 27G .0104 preferred. Preferred licensure/certification: * National Certified Investigator & Inspector Training and Certification is preferred. 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. RESIDENCY REQUIREMENT: Prefer incumbent reside in North Carolina or within 40 miles of the North Carolina border. SALARY: Depending on qualifications & experience of candidate. This position is non-exempt and is eligible for overtime compensation. DEADLINE FOR APPLICATION: Open until filled APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/ [https://www.vayahealth.com/about/careers/]. Vaya Health is an equal opportunity employer.

Responsibilities

The Quality Management Specialist is responsible for resolving member and provider grievances and complaints, processing incident reports, conducting site reviews, and assisting with various quality assurance systems like NC TOPPS and HCBS Assessments. This role ensures compliance with applicable laws and regulations throughout the resolution and monitoring processes for services funded by Medicaid, waivers, and state funding.