External Review Specialist; Remote NC

LOCATION: Remote
-must live in North Carolina or within 40 miles of the NC border. This position is remote, but the applicant must have the ability to travel to Vaya's Office if needed.

GENERAL STATEMENT OF JOB

The External Review Specialist supports the organizational oversight and management of external reviews, including readiness reviews for new programs. This position plays a key role in ensuring the organization's continued compliance with requirements imposed by external sources, including, but not limited to, the NC Department of Health and Human Services (NCDHHS) and its divisions and authorized vendors, including the Division of MHDDSUS, the Division of Health Benefits (NC Medicaid), and the External Quality Review Organization (EQRO) as well as supporting the Quality Management Department with compliance with NCQA accreditation requirements.

This position collaborates with all departments at Vaya Health and supports overall program objectives.

ESSENTIAL JOB FUNCTIONS

Regulatory Organizational Oversight and Management of External Reviews:

• Support and/or assist in organizing external reviews including, but not limited to, External Quality Reviews, NCQA, TCLI DOJ and Diversion Audits, semi-annual audits required by Senate Bill 208, Readiness Reviews, HUD, DMH Systems Review, as well as any others as they occur or become known. This includes desk reviews, on-site and virtual reviews as well as live system demonstrations, along with monitoring for and implementing updates via training, policy changes, mock reviews, corrective action plans and potential audits to ensure compliance.
• Maintain an organizational database to track upcoming reviews and to monitor accurate and timely submission of external reviews as well as any plans of correction.
• Coordinate and assist Vaya Departments/Teams in the successful completion of external reviews, including reviewing documentation prior to submission.
• Coordinate with the Office of Communications, Legal Department and Area Director and Chief Executive Officer to ensure any new or updated documentation needed for external reviews is vetted and approved prior to submission.
• Work with staff to address and follow-up on any plans of correction issued by external oversight authorities.
• Conduct audits on plans of correction to ensure successful implementation.
• Maintain a database to track corrective action items and, should systemic issues be identified, coordinate with the Compliance Department for inclusion on the risk register for possible mitigation.
• Ensure schedules, timelines, due dates, and updates for any external reviews are maintained and timely communicated to the External Review Manager, Regulatory Affairs Director, and VP of Regulatory Affairs.
• Assist with setting goals for external reviews and associated deliverables.
• Develop and maintain an ongoing external review report, providing project updates to the External Review Manager, Regulatory Affairs Director, and VP of Regulatory Affairs.
• Conduct periodic reviews of policies to ensure compliance with external review requirements and work with the External Review Manger to update policies as needed.
• Assist in the development of training plans as they relate to external reviews.
• Provide coverage on meetings, both internal and external, as needed.

Other Duties as Assigned.

Note this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

KNOWLEDGE, SKILLS, & ABILITIES

• Strong knowledge of state and federal laws, rules, regulations, contract requirements, and practices related to Vaya Health's operations in North Carolina is beneficial.
• Strong project coordination and administration background with the ability to work with organizational leadership to collect information.
• Knowledge of policy and procedure drafting and editing with practical experience in applying that knowledge.
• Ability to identify areas of improvement or correction in a professional and constructive manner.
• Ability to review deliverables and other documentation to identify accuracy and completeness.
• Ability to complete tasks in a timely and accurate manner.
• Excellent time management skills and the ability to manage competing priorities and projects.
• Strong organizational skills with attention to detail and the ability to multi-task.
• Ability to work independently with little or no direction, demonstrate initiative, be goal-oriented, and function as a self-starter.
• 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.
• Highly effective oral and written communication skills are required, including strong presentation skills and proficiency in grammar, punctuation, and spelling.
• Exceptional interpersonal skills, diplomacy and conflict resolution…