Provider Quality of Care Specialist (Remote NC)

LOCATION: Remote - may live anywhere in Vaya's catchment area in North Carolina; however, there is a preference for the Charlotte NC area. This position requires travel as needed.

GENERAL STATEMENT OF JOB

The Provider Quality of Care Specialist serves as a vital member of the Quality Management Department and reports directly to the Provider Quality Assurance Manager. This position plays a critical role in ensuring the delivery of safe, high-quality and compliant services across Vaya's provider network.

Key responsibilities include assessing and responding to quality-of-care concerns and completing health and safety screenings. The person in this position triages quality of care concerns entered in Vaya's EthicsPoint database and collaborates with internal and external stakeholders to address concerns and ensure timely follow-up. This role is also responsible for appropriately escalating urgent member concerns to department leadership and contributing to the development of solutions that support member safety.

This position ensures that provider services delivered are consistent with funding requirements, best practices, provider's contracts, and federal/state rules and regulations. Research, reporting, and providing technical assistance are key functions of this role to support continuous quality improvement. Additionally, this role involves coordinating and performing - in-person screenings at home and community-based settings to ensure member health and safety.

ESSENTIAL JOB FUNCTIONS

The incumbent in this position serves as part of a monitoring team and will work as a part of that team to complete monitoring of network providers. Responsibilities include:

Triage Quality of Care Concerns and complete required follow up review activities:

• Monitor and triage quality of care concerns received in Vaya's EthicsPoint database. Review new quality of care concerns and determine appropriate follow-up action needed to address any identified issues. Follow-up actions may include, but are not limited to:
  • Researching provider contract requirements, State and Federal regulations, member service history, and incident report information.
  • Conducting outreach to request pertinent case information from providers, Vaya staff, and external stakeholders.
  • Staffing urgent quality of care and health and safety concerns with the Provider Quality Assurance Manager.
  • Escalate concerns to Quality Management leadership as appropriate.
• Support work-flow management by partnering closely with the Provider Quality Assurance Manager to ensure tasks assigned to the team are complete and meet set timelines.
• Report concerns to external regulatory agencies as needed.
• Provide technical assistance to educate providers on contractual requirements.
• Complete case notes and update all required case fields in EthicsPoint to document activities within required timelines.
• Participate in multidisciplinary meetings and contribute to quality improvement initiatives as assigned.

Health/Safety Checks:

• Collaborate with the Provider Quality Assurance Manager to coordinate announced or unannounced Health and Safety Checks.
• Conduct announced or unannounced Health and Safety checks as needed and/or assigned to assess quality of care and ensure member Health and Safety.
• Complete documentation from reviews as requested
• Complete announced unlicensed alternative family living (UAFLs) reviews to assess compliance with health and safety requirements for urgent and expedited placements. Serve as back up for UAFL reviews.
• Review HCBS assessments for any urgent and expedited placements as assigned.

Other duties as assigned:

• Serve as an additional reviewer for focused reviews and investigations.
• Review provider Plans of Correction as assigned.
• Assist in developing dashboards and presentations for internal and external stakeholders.
• Review and process Relative as Direct Support Employee (RADSE) requests as assigned.

KNOWLEDGE, SKILLS, & ABILITIES

Success in this position requires exceptional interpersonal skills, and highly effective communication ability. A high level of diplomacy and discretion is required to effectively negotiate and resolve issues. In addition, the person in this position must have:

• 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.
• Ability to analyze and interpret policy and procedural guidelines.
• Ability to problem solve, critically think, analyze, interpret and apply data obtained and make recommendations to support member safety and business needs.
• Ability to work independently with little or no direction, demonstrate initiative, and function as a self-starter.
• Excellent time management skills and the ability to reprioritize in a fast-paced environment and keep up with multiple, possibly competing, priorities.
• Effectively work in a complex healthcare environment in a highly collaborative manner keeping all stakeholders informed as appropriate.
• A high level of diplomacy and discretion is required to effectively negotiate and resolve issues.
• Strong negotiation and conflict resolution skills to manage sensitive issues and drive consensus.
• Ability to establish and maintain positive and effective working relationships with others.
• Experience in assigning tasks, managing workloads, and monitoring team performance to ensure quality and timeliness.
• Ability to anticipate challenges, assess risks, and make informed decisions that support members' safety and service quality.
• Ability to effectively present information and respond to questions from internal and external stakeholders in a professional and concise manner.
• Excellent computer skills; proficiency in Microsoft Office Suite; and experience creating documents, forms, and graphs.
• Skilled in organizing workflow and strong detail orientation.
• Exceptional written and verbal communication skills including excellent skills in English grammar, punctuation, and spelling, and ability to clearly communicate complex ideas and concepts

EDUCATION & EXPERIENCE REQUIREMENTS

• A Bachelor's Degree in a Human Service field and two years of experience in the field of mental health, intellectual and developmental disabilities, or substance use disorders is required.

OR

• A Bachelor's Degree in a field other than Human Services and six years of experience in the field of mental health, intellectual and developmental disabilities, or substance use disorders is required.

Meeting the criteria of being a North Carolina Qualified professional in 10A NCAC 27G .0104 is preferred.

Licensure/Certification Required:

• CLEAR/NCIT Basic Certified Investigator (certification should be completed within the first 9 months of employment)

Preferred work experience:

• Three or more years experience in the field of mental health, intellectual and developmental disabilities, or substance use disorders is preferred.
• Meeting the criteria of being a North Carolina Qualified professional in 10A NCAC 27G .0104 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: May live in Vaya's catchment area in North Carolina or within 40 miles of the North Carolina border. However, there is a preference for the Charlotte NC area.

SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not 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.