Quality Assurance Reviewer, SCDDSN

Job Description

Job Description

Alliant Health Solutions, a "Best Place to Work" and "Healthiest Employer", seeks a Quality Assurance Reviewer!

The Quality Assurance Reviewer , as a member of a professional multi-disciplinary work team, is responsible for the quality assurance reviews and monitoring of policy compliance for the South Carolina Department of Disabilities and Special Needs (SC DDSN)  Quality Assurance Review program. They conduct case review activities including record review, observation and evaluation of Residential Habilitation and Day Services, reviews of providers’ plan of correction, follow-up reviews and special circumstance reviews. They also conduct consumer interviews.

ESSENTIAL JOB FUNCTIONS:  

• Perform desk review through analysis and review of previous review findings and begins case activity log in developing the appropriate approach for the on-site review.
• Conduct on-site reviews for the specified SC DDSN providers which includes some but not all the following: exit and entrance sessions with the appropriate management and clinical staff from the provider location, staff interviews, and document(s) review.
• Notify providers in advance of upcoming on-site visits. Conducts entrance and exit interviews with providers informing them of purpose of visit and preliminary findings.
• Make recommendations based on professional judgment and experience for the compliance with SC DDSN standards, the necessity/quality of the services and the appropriateness of the setting while substantiating recommendations with clinical rationale. 
• Analyze, interpret, and document appropriate determination review outcomes utilizing the MedGuard review system.
• Prepare timely, accurate, written letters/reports to providers/SC DDSN on initial on-site and follow-up desk/on-site review findings. 
• Review additional information related to requests for follow-up reviews after initial findings and makes a recommendation based on professional judgment and experience for the compliance with SC DDSN standards, the necessity/quality of the service and the appropriateness of the setting.
• occasionally serve on panel of peers to provide professional expertise regarding standards of service delivery.

OTHER JOB FUNCTIONS:

• Work in close collaboration with other team members to support the development of new projects and the continuous improvement of the overall work of the team.
• Promote core values of teamwork, professionalism, effective communication skills and positive behavior.
• Maintain security and confidentiality of all information in accordance with HIPAA (Health Insurance Portability and Accountability) laws and regulations and company policies.
• Demonstrate compliance with company corporate and departmental policies as evidenced by attendance, punctuality, and dress.
• Perform other duties as assigned

KNOWLEDGE, SKILLS, AND ABILITIES :

• Strong theoretical clinical knowledge base and problem-solving skills.
• Strong organizational skills with ability to demonstrate work priorities.
• Demonstrate ability to perform work with considerable independence by use of creative thinking, thorough analysis of problems, and use of innovative approaches to problem resolution.
• Moderate computer skills (Excel and Word) including word-processing (30-50 WPM) and data entry skills required.
• Excellent interpersonal, written, and verbal communication skills required.
• Excellent telephone skills, including ability to handle difficult calls/callers.
• Computer literate
• Ability to travel by car or plane to Company locations, customer meetings or other locations as needed.

EDUCATION, EXPERIENCE, AND TRAINING:

• Bachelor's degree in social work, Sociology, Psychology, Nursing (BSN) or other Human Services degree 
• A minimum of 3 years of previous SC DDSN, Medicaid, Mental Health Utilization Review, Case Management, Quality Assurance, Claims Auditing, and/or Fraud/Abuse experience

Preferred, but not required:

• Registered Nurse or Social Worker with current and unencumbered South Carolina license
• Previous clinical experience working with individuals with developmental disabilities

PHYSICIAL REQUIREMENTS:

Essential duties are routinely performed in a professional office environment but may be conducted in remote or field locations. The role may require work at a station/desk and routinely requires use of standard office equipment such as computers, phones, photocopiers/scanners, fax machines, printers, and filing cabinets. Duties may require the use of transportation to attend meetings or conduct duties outside of the office environment. Must be able to regularly remain in a stationary position and occasionally move about the office to access office machinery and facilities. Occasionally must be able to move/transport materials weighing up to 30 pounds, as well as position self to access files, equipment, and work materials. This role frequently communicates to internal and external resources both verbally and written, via face-to-face, electronic, and telephonic media. Must be able to understand and exchange accurate information in these situations, as well as translate into action. Short-term and long-term memory, abstract reasoning and decision making may be required on a regular basis. Core office / business operational hours may be required.

ADA/ADAAA/SECTION 503 NOTIFICATION:

In compliance with the ADA, the ADA Amendments Act (ADAAA) and Section 503 of the Rehabilitation Act), should you have a disability and would like to request a reasonable accommodation, please see Human Resources to begin the interactive process.

DISCLAIMER:   This job description indicates the general nature and level of work expected of the incumbent. It is designed to cover or contain a comprehensive, but not all-inclusive, listing of activities, duties, tasks, and/or responsibilities as required for Employee.  Employee may be asked to perform other duties and responsibilities as required.