Wellness and Recovery Clinical Compliance Inspector I

To work with a dedicated and committed team, the site review inspections team, to oversee and implement Wellness and Recovery Site Reviews, provide education to Wellness and Recovery provider sites and to assess and improve the quality of care delivered by providers.

Responsibilities

Performs Facility Site Reviews per contractual requirements.

Performs Medical Record Review and Treatment plan reviews per contractual requirements.

Provides education to site’s providers and staff as needed, to help with overall improvement and compliance.

Works closely with sites to disseminate QI information and offer technical assistance to correct deficiencies. Monitors provider’s progress towards meeting set goals.

Implementation of ongoing and focused monitoring activates to detect adverse health outcomes and other related issues.

Refers cases for appropriate peer review when established criteria is not met.

Assists in the investigation of potential quality issues identified at the provider level via a variety of available identification tools.

Participates in monthly Peer Review Committee, while ensuring confidentiality of peer review records and process.

Assists in data collection and analysis for review of the appropriate committee.

Facilitates or participates in improvement teams or committees, as assigned.

Participates in and leads special projects and assignments, as required.

Active involvement in HEDIS abstractor training and improvement efforts.

Considerable travel required to all contracted facilities to conduct site reviews and provider educations.

Secondary Duties and Responsibilities

Provides clinical support to the project coordinators, project managers and/or analytical staff.

Assists in recommendations for improvement.

Facilitates or participates in improvement teams as directed by QI Leadership.

Maintains current knowledge of NCQA accreditation; US Center for MediCal and Medicaid services and California Department of Healthcare Services requirements and Health plan's' compliance related to Quality Measurement and Improvement, Site review, Peer Review and Credentialing.

Other duties as assigned.

Qualifications

Education and Experience

Required: BSN or Bachelor’s degree in an applicable field andminimum three (3) years clinical experience required. Experience inquality improvement or quality management, managed care; facilitysite review; HEDIS and Title 22 preferred

Special Skills, Licenses and Certifications

Current California RN, MFT, LMFT, or Registered AMFT required.Knowledge of healthcare total quality management theory, practices,standards and applicable laws and the ability to access data andinformation using electronic record systems required. Valid CaliforniaDriver's license required.

Knowledge of NCQA/HEDIS standards. Familiarity with businesspractices and protocols preferred.

Performance Based Competencies

Proficiency in MS Word and Excel. Excellent oral and writtencommunication skills. Ability to facilitate groups and tasks. Excellentplanning and organizational skills. Efficient; follows-through oncommitments; attention to details. Flexible and adaptable to competingpriorities, strong team player and able to remain calm under pressure.

Work Environment And Physical Demands

Must be able to work in a fast paced environment and maintaincourtesy and composure when dealing with internal and externalcustomers: Ability to prioritize work load and initiate action. Ability tofunction effectively with frequent interruptions and directions frommultiple team members. Standard cubicle work station with sharedcommon area. Use of telephone, fax, computer and photocopyingmachine is required. Requires sitting in front of computer equipmentand talking on telephone for major portion of the workday. Must beable to move, lift or carry objects varying in size, weighing up to 35lbs. Must be able to operate a vehicle used for company business.

All HealthPlan employees are expected to:

Provide the highest possible level of service to clients;

Promote teamwork and cooperative effort among employees;

Maintain safe practices; and

Abide by the HealthPlan’s policies and procedures as they may from time to time be updated.

HIRING RANGE:

$103,059.95 - $133,977.94

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

Regular Full-Time