Clinical Quality Manager

Job Description

Job Description

Overview

The Clinical Quality Manager is responsible for a variety of tasks oriented toward maintaining or improving clinical quality across the organization, with a focus on clinicians (i.e., Board Certified Behavior Analyst (BCBA), and Board Certified Assistant Behavior Analysts (BCaBA), clinical training, continuing education, and the insurance processes. Specifically, the Clinical Quality Assurance Manager reviews client treatment plans and associated clinical documentation, provides feedback and sets deadlines for task completion, disseminates information related to clinical quality standards across the organization as needed, provides tools and resources that enable clinicians to perform clinical duties more efficiently, participates in clinical quality improvement projects as designated and other tasks as assigned. In addition, this role will assist with the overarching insurance processes, including facilitating appropriate continuity of services and appropriate communication internally, as well as externally (e.g., insurance funders, client families, etc.). The Clinical Quality Assurance Manager reports directly to the Director of Clinical Quality and Compliance. This role would be hybrid Clinical QC with a small clinical caseload. This position requires for you to be open to other locations at Gateway.

Responsibilities

• Review all clinical documents to be submitted to insurance providers for the purpose of obtaining authorizations of service, modifying existing authorizations, or meeting funder requirements. These documents include assessment reports, treatment plans, progress updates, behavior intervention plans, graphed data, supplemental insurance-specific forms, and addenda to any of the former.
• Collaborate with insurance providers as needed to assist with review calls, pre-authorizations and retrospective authorizations, client benefits, and client current and future application of feedback.
• As necessary, request and set deadlines for clinicians to edit clinical documents prior to submission; conduct a final review of documents according to recognized standards of clinical practice, Gateway policies and procedures, and the requirements of various insurance providers.
• Coordinate (and participate in as needed) subsequent reviews of clinical documents at the request of care managers or other recipients of authorization requests.
• Obtain and manage authorizations, including relaying this information to the other departments as appropriate. This may include regular virtual and in-person meetings as appropriate.
• Design and maintain systems to track internal deadlines for completion of clinical documents, dates of submission, and other information relevant to client treatment plans and county requirements.
• Conduct treatment planning seminars as needed for clinicians who are new to the organization and/or practicum students and ongoing training for clinical teams, as relevant.
• Participate in the creation, dissemination, and monitoring of internal continuing education or staff development opportunities as needed.
• Maintain electronic files consisting of tools that clinicians can use to create programs, develop treatment plans, and complete other clinical activities in line with clinical quality standards more efficiently.
• Participate in troubleshooting insurance changes, issues, and/or lapses to facilitate continuity of services and minimize financial impact to consumers and company.
• Assist with internal case review in order to provide transition recommendations on an as-needed basis.
• Support identified team members during audits, both internal and external.
• Coordinate with supervisor to identify clinical quality improvement needs across the organization; develop and initiate clinical quality improvement projects.
• Manage and maintain accurate client records and requests in accordance with company needs and standards.
• Maintain client privacy in accordance with all HIPAA regulations and with Gateway policies and procedures manual.

Qualifications

• Bachelor’s or Master’s Degree in Behavior Analysis or a related field.
• Previous experience working as a clinician with a variety of consumers/managing a caseload.
• Previous experience with providing verbal and written feedback.
• Experience with a variety of clients, ages, and skill levels preferred.
• Experience with a variety of skill based assessments preferred.
• Employed as a clinician with Gateway Pediatric Therapy preferred.
• Current BCBA or BCaBA certification.
• Current LBA or LABA licensure.
• Must be in good standing with the BACB.
• Proficiency in report writing with a specific emphasis on reports for Medicaid funders.
• Strong interpersonal and communication skills.
• Organizational proficiency.
• Strong time management skills.
• Ability to work both independently and in a team environment.
• Working knowledge of Google Suites, and other enterprise platforms preferred.

• Travel to other clinic locations is not routine but is required intermittently for clinical quality improvement projects that require in-person attendance per the supervisor’s discretion or pertaining to other tasks as assigned by the supervisor.

• Hybrid of in office and work from home per the discretion of direct supervisor. Work from home environments must comply with privacy and HIPAA guidelines.