The Quality Management Specialist (Policies & Procedures) assists with the implementation and oversight of quality and compliance activities, health information management, and analytic reporting for Prime Care Coordination. In conjunction with the Director of Quality & Compliance and leadership team, the Quality Management Specialist will contribute to the execution of the strategic direction and brand of care coordination for the CCO/HH that aligns with the long term vision and goals of the I/DD service delivery system transformation to managed care.
Essential Job Functions:
- Remain abreast of current and proposed regulations pertaining to Quality and Corporate Compliance and act as a resource for information; coordinate guidance and training to all PCC programs.
- Work in coordination of Care Coordination Program leadership to respond to regulatory changes.
- Respond and coordinate with OPWDD or DOH, assist in the development, implementation, and monitoring to Quality / Compliance policies and procedures for PCC and ensure employee workforce education and training.
- Responsible to maintain PCC P+P manuals and online inventory of all policies and procedures. In coordination with training staff, ensure that staff have access to all the latest policies and procedures.
- Assist with training and monitoring of policies and procedures for HIPAA Privacy in accordance with the federal HIPAA Rule and Omnibus Act. Respond to alleged HIPAA privacy violations. Assist in the implementation and oversight of a uniform system for handling of such violations. Ensure proper reporting of HIPAA privacy violations as required.
- Respond to alleged violations of rules, regulations, policies, procedures, and the Code of Ethical Conduct by evaluating or recommending the initiation of investigative procedures; assist in the implementation and oversight of a uniform system for handling of such violations.
- Maintain and distribute reports on the success of quality programs driven by statistics; to include audit findings and analysis of trends, patterns, systemic issues, and potential quality improvement opportunities.
- Assist with oversight of internal audit functions/assessment tools/checklists for all PCC programs as necessary to ensure compliance and quality care.
- Complete investigations as well as special and internal control audits as assigned by the Director of Quality & Compliance.
- Serves as a member of the Quality Management team and engage in general quality and improvement activities including satisfaction survey process related to families and individuals served.
- Participate on quality committees and sub-committees
- Perform other duties as assigned by supervisor
Knowledge, Skills, and Abilities:
- Knowledge of OPWDD and/or DOH regulations, programs, and service delivery system including knowledge of audit, policy/procedures, quality assurance regulations, Medicaid Service Coordination, managed care or services for people with intellectual and developmental disabilities and/or health home care management.
- Must be able to multi-task, establish priorities, and meet deadlines.
- Ability to work in a collaborative environment, work independently, and motivate others.
- Ability to communicate effectively, both orally and in writing.
- Ability to act quickly, assess, and act appropriately in crisis situations
- Proficient with technology and understanding of health records
- Maintain appropriate confidentiality and discretion at all times.
Education and Experience:
- Bachelor’s Degree in Healthcare, Business, Human Services Administration, or related field.
- Minimum 3 years of experience in Quality Management (Policies & Procedures) areas within a health care or human services setting.
- Possession of valid, unrestricted NYS driver’s license required
Physical Requirements/Working Conditions:
- Ability to sit continuously
- Ability to reach above shoulder level
- Ability to turn/twist upper body
- Ability to use hand for repetitive action and fine manipulating for the purpose of keyboarding
- Must be able to travel to PCC regional locations as required
- Adhere to all Prime Care Coordination policies and procedures.
- Adhere to the organization’s Mission, Vision, Values, and Customer Service Standards.
- Attend mandatory education and training modules as scheduled; obtain and maintain certifications/training required by State regulations and/or Prime Care policy
- Act as a professional representative of the organization in regards to appearance, behavior, temperament, communication, language, and dress.