Description

Under general supervision, the Quality Management Specialist is responsible for completing audits and investigations as required and informed by regulatory oversight agencies. Through audits and investigations, the Quality Management Specialist will identify, analyze, report, and make recommendations for improving the organizations adherence to internal controls and regulatory requirements in Medicaid and non-Medicaid funded programs. The Quality Management Specialist will lead efforts to maintain an updated and consistent understanding of internal controls and regulatory requirements across the agency.

Essential Duties and Responsibilities

• Independently plans and performs all steps of assigned internal program audits to include, evaluating data against regulatory requirements, billing standards, and internal policies, communicates findings, and reviews corrective action plans put in place in response to findings.
• Works with QMC peers to establish an annual audit plan as informed by Compliance workplan, Compliance Program Effectiveness Review, risk assessments, prior audit & investigative findings, and OMIG workplan.
• As assigned, supports programs with external audits/monitoring visits to include reviewing corrective action plans.
• Investigates and monitors issues of non-compliance and coordinates with the program to implement appropriate internal controls
• Conducts investigations into reported compliance concerns, including breaches of HIPAA/privacy, under the direction of the Regional Compliance Officer.
• Conducts investigations into allegations of abuse, neglect, and other significant incidents under the direction of the Director of Quality & Incident Management or Regional Compliance Officer.
• Provides written investigative report including findings and recommendations to designated program staff, leadership team, Incident Review Committee(s), and applicable state/federal oversight agencies.
• Provides accurate documentation of formal investigations to all designated state or federal oversight agencies as required.
• Provides support in conducting the agency risk assessment and assists in managing workplan.
• Develops and implements QMC policies and procedures as required using policy database/repository.
• Assists in developing educational materials and trainings related to Quality Management and Compliance functions
• Provides impartial and unbiased judgment in performance of job duties
• Adheres to all applicable federal and state laws, including but not limited to those governing client confidentiality, privacy, program standards and billing and documentation standards
• Maintains high level of expertise in specialized areas through continuing education, individual contacts, and attendance at appropriate meetings
• Awareness and active support of the Agency's Mission, Vision, Values and Strategic Plan. Including, but not limited to, supporting the Agency's Core Competency initiatives of being Collaborative and Community Focused, Innovative and Entrepreneurial, and Culturally Competent and Diverse
• Other duties as assigned

Note: The above description is illustrative of tasks and responsibilities. It is not meant to be all inclusive. Employees are required to follow appropriate supervisory direction and perform other related duties as required.

Qualifications

Education: Bachelor’s Degree in Human Services, Business Administration, or related field required.

Credentials: Certification/training in Conducting Serious Incident Investigations from Labor Relations Alternatives, or the ability to obtain within 90 days of hiring

Experience: Three to five years of operations or audit/investigation experience in programs under the oversight of DOH, OASAS, OMH, OPWDD, or similar state/federal agency required. Knowledge of regulatory guidelines and practices. Excellent verbal and written communication skills. Demonstrated proficiency with high attention to detail and maintaining confidentiality.

Equivalent combination of education and experience will be considered

Physical Demands/Work Environment: The physical demands/work environment described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.While performing the duties of this job, the employee is frequently required to sit, talk, hear, stand, walk, use hands to type and/or perform light lifting. Specific vision abilities required by this job include close vision, distance vision and ability to adjust focus.The noise level in the work environment is usually quiet.

Compliance: Adheres to all applicable federal and state laws and regulations including, but not limited to, those governing confidentiality, privacy, program, billing and documentation standards. All duties must be performed in accordance with CFC’s corporate compliance & ethics program.

Additional Requirements: