Director of Quality Assurance

The Agency is a well-respected nonprofit mental health agency with multiple sites in Alameda County.  The Agency is also a social rehabilitation agency providing a full range of Medi-Cal services to adults with co-occurring serious mental health and substance use disorders.

The Agency fully supports the Board of Behavioral Sciences' commitment to protect the consumers of California through effective enforcement, ensure credibility and high professional standards through examinations and licensing requirements, and provide excellent customer service to all its constituents.

Position Summary:

This position will be responsible for assuring compliance with governmental, and external agencies’ standards, policies, and procedures for quality and accurate documentation. Manages the utilization review process for Medicare and Medi-Cal services provided in our case management, residential treatment, and day rehabilitation services. Performs charts reviews and internal audits, authorizes documentation, provides training to and interfaces with paraprofessional and professional staff members, and external review agencies to ensure clients receive the best and most appropriate care. Appeals adverse decision by external agencies when necessary.

Qualifications:

Required:

• The Utilization Review Coordinator must be a Licensed Clinical Social Worker, Marriage and Family Therapist, Licensed Professional Clinical Counselor
• Psychiatric Registered Nurse, or Clinical Psychologist with one (1) year of experience in the Medi-Cal utilization review process.
• Understanding of pertinent laws and regulations regarding mental health and social service programs and the ability to apply state, federal, and local regulations related to quality assurance and utilization review.
• Knowledge of Medicare and Medi-Cal specialty mental health services as provided in community social rehabilitation agency preferred.
• Must be able to demonstrate the ability to effectively, sensitively, and respectfully relate to people from different cultural groups. Candidates must be literate with electronic health record systems.
• Must meet the Immigration Reform Act of 1986 requirements.

KPIs:

1. Clinical:  Maintain knowledge of Medi-Cal/Medicare regulations by attending annual training and Ensure that 100% of clinical staff receive annual documentation training/ annual updates
2. Fiscal:  Reduce financial risk from Medi-Cal audits – The Agency will receive <95% approval rating in Medi-Cal audits.
3. Quality Review:  Conduct monthly CQRT internal authorization to maintain Medical standards for all The Agency Programs as documented by 100% completed 485 Reports in Insyst by end of Month.
4. Quality Review:  Conduct quarterly Peer Review internal chart audits with participation by all Program Directors as documented by maintenance of Peer Review Binder containing quarterly Peer Review forms signed by participating Program staff.
5. Utilization Review:  Develop Outcome Reports for process improvement pertaining to:  Critical Incidents, audit finding, for use by Quality Improvement Committee.

Essential Functions/Skills:

• Responsible for planning, organizing, developing, evaluating, and when necessary, revising The Agency Utilization Review processes.
• Works with county, state and federal representatives to ensure The Agency complies with Medi-Cal utilization review regulations.
• Provides training and information on Medicare and Medi-Cal Utilization Review requirements to clinical, supervisory, and management staff.
• Tracks and reviews client’s Medicare/Medi-Cal documentation to ensure compliance with state and federal regulations relating to medical necessity and accuracy of all documentation.
• Conducts regular chart and client service audits.
• Establishes and maintain positive, collaborative relationships with program staff,
• Participates with staff in utilization and quality improvement meetings and projects.
• Coordinates with administrative staff to ensure that services delivered are the services billed.
• Compiles, tracks, and review denied services; represents The Agency in appeal of any adverse decisions.
• Coordinates the Peer Review process in collaboration with the Clinical Services Director.
• Provides retrospective reviews of Critical Incidents and Sentinel Events.
• Develops outcome reports and presents data for distribution.
• Performs other duties as assigned.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully preform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Physical demands. Must be able to lift 50 pounds.

EOE AA M/F/V/Disability:

The Agency is committed to providing equal opportunity to all qualified persons regardless of race, color, citizenship status, national origin, ancestry, gender, pregnancy, sexual orientation, gender identity or expression, genetic information, age, religion, creed, physical or mental disability, marital status, veteran status or any other characteristic protected by law (“Protected Status”).