Clinical Specialist - Performance Monitor (HC

Under the general supervision of the Director of Quality Improvement, the Clinical Specialist - Performance Monitor (HCBS) is responsible for conducting provider reviews and ensuring the compliance of assigned providers to federal, state, local, contractual, regulatory and best practice standards and guidelines.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Assists in conducting organizational studies and evaluations.
• Designs systems and procedures.
• Conducts work simplification and measurement studies.
• Prepares operations and procedures manuals.
• Uses data analytics to identify claims/encounters that cannot be valid or more likely not valid.
• Identifies and documents the sampling methodology used to determine sampling and test data elements from individual claims/encounters to be validated against clinical records.
• Performs review of provider clinical case record documentation through desk audits, compliance investigations and on-site provider reviews.
• Ensures all claims identified in the sample size are reviewed and corrective action plans are followed as required.
• Reviews data elements from individual claims/encounters to verify: a) code is approved under this contract, b) eligibility of the beneficiary on the date of service, c) service is included in the beneficiary's individual plan of service, d) the date/time of service, e) service provided by a qualified practitioner and falls within the scope of the code billed/paid.
• Monitors Home Community Based Setting (HCBS) projects on a monthly basis.
• Monitors providers who render non-residential and/or residential services to ensure full compliance with the HCBS Final Rule.
• Reviews clinical case records to ensure the HCBS requirements are reflected in the member's plan of service.
• Analyzes data collected from surveys and notifies providers of corrective action plans as required.
• Reviews modifications of the conditions under 42 CFR to ensure specific assessed needs are supported through the plan of service and that it includes all documentation required by this element and the HCBS Final Rule.
• Develops and implements HCBS policies and procedures for HCBS settings.
• Ensures CAP's are implemented and successful by performing follow up audits.
• Reviews provider's policies and procedures to ensure they are consistent with the HCBS Final Rule.
• Develops an automated Provider scorecard.
• Maintains performance standards with HCBS requirements.
• Verifies corrective actions from providers who are found out of compliance in their Medicaid Verification review.
• Ensures CAP's are implemented and successful by performing follow up audits.
• Verifies recoupment from providers whose claims/encounters are determined to be invalid.
• Identifies specific coding risk areas and strategies to promote accuracy, compliance, detection and correction of potential risk exposures.
• Develops and provides reports on audit findings and recommendations.
• Develops an automated Provider scorecard.
• Assists the Compliance Team on OIG, other government audits/reviews and other compliance-related work.
• Establishes professional relationships with stakeholders and community agencies to facilitate quality processes internally and externally.
• Inputs data into established database to generate required monthly reports for monitoring compliance of assigned providers.
• Ensures compliance with MDHHS site visit performance standards (Medicaid, SED Waiver, HSW Waiver, Autism, Certification, etc.) of the assigned provider.
• Maintains performance standards for Claims Verification.
• Maintains performance standards for MMBPI.
• Performs related duties as assigned.

KNOWLEDGE, SKILLS AND ABILITIES:

• Knowledge of DWIHN policies, procedures and practices.
• Knowledge of the DWIHN provider network and community resources.
• Knowledge of the Michigan Mental Health Code.
• Knowledge of MDHHS policies, rules, regulations and procedures.
• Knowledge of medical and behavioral health practices and terminology.
• Knowledge of compliance standards.
• Knowledge of the Federal Confidentiality Regulations, 42 CFR, Part 2.
• Knowledge of documents / regulations that govern the provision of mental health services, e.g., Medicaid Manual Mental Health and Substance Abuse Chapter III, State Plan for Medicaid, Michigan Department of Health and Human Services Quality Plan, BBA requirements and the Mental Health Code.

• Knowledge of medical terminology.
• Knowledge of billing and coding.

• Knowledge of regulatory and industry best practice standards.
• Knowledge of the principles and methodology of total quality management (TQM)/ continuous quality improvement (CQI), specifically the PDSA/PDCA Cycle, quality tools and techniques, and models for improvement.
• Knowledge of claims verification, monitoring and auditing.

• Assessment skills.
• Organizational skills.
• Planning skills.
• Analytical skills.
• Time Management skills.
• Report writing skills.
• Problem Solving skills
• Communication skills.
• Written communication skills.
• Accuracy and detailed oriented skills
• Computer skills
• Ability to communicate orally.
• Ability to communicate in writing.
• Ability to work effectively with others.
• Ability to work with an ethnically, linguistically, culturally, economically and socially diverse population.
• Judgement/Reasoning ability.

REQUIRED EDUCATION:

A Bachelor's Degree in Social Work, Psychology, Counseling, Nursing, Quality Management, Health Administration, Public Administration, the Human Services, the Social Services or a related field.

REQUIRED EXPERIENCE:

Five (5) years of professional experience in behavioral healthcare including at least (2) two years of experience performing the following functions:

Quality management/quality improvement functions.

OR

Claims verification, monitoring or auditing.

REQUIRED LICENSE(S):

A valid State of Michigan Driver's License with a safe and acceptable driving record.

WORKING CONDITIONS:

Work is usually performed in an office setting but requires the employee to drive to different sites throughout Wayne County and the State of Michigan.

This description is not intended to be a complete statement of job content, rather to act as a general description of the essential functions performed. Management retains the discretion to add or change the position at any time.

Please Note: DWIHN requires proof of being fully vaccinated for COVID-19 as a condition of employment. Medical or religious accommodations or other exemptions that may be required by law, will be approved when properly supported. Further information will be provided during the recruitment process.

The Detroit Wayne Integrated Health Network is an Equal Opportunity Employer