Quality Management Specialist (Remote NC)

LOCATION : Remote - preference for incumbents that 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 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.

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;

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 :

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 :

Health / Safety Reviews including any Site Review

Investigations :

Additional Tasks :

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.

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

EDUCATION & EXPERIENCE REQUIREMENTS

High school diploma or GED required. Bachelor's degree in a Human Services field preferred. Must have

OR

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 :

Preferred licensure / certification :

PHYSICAL REQUIREMENTS

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 / .

Vaya Health is an equal opportunity employer.