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.

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.

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:

• 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.

• 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 likelihood that the incident will be in the media and alert the CMO

Tracking and trending of incidents; report any…