CSP Utilization Review Specialist/Quality Manager

Under general direction, of the Associate Administrative Director of Centered Spirit, the Utilization Review Specialist/Quality Manager is responsible for coordinating the implementation of the quality management/utilization review systems and activities of the Pascua Yaqui Centered Spirit Program (PYCSP).

• Coordinate implementation of a wide range of quality management/utilization review function including information management, outcomes management, utilization review, policy and procedure, development/monitoring, report activities as required by AHCCCS, CARF, Indian Health, and Yoeme Health Services.
• Co-Chair quarterly Quality Management/Utilization Review Committee meetings.
• Provide training to all staff in the area of Quality and Improvement.
• Develop and implement the PYCSP Strategic Plan for Performance Improvement.
• Track outpatient service utilization provided by PYCSP for all clients (including those identified as SMI or SED), for days of stay at inpatient and residential facilities; ensure outpatient facilities meet state requirements concerning IMD placements.
• Write and distribute quarterly PYCSP reports and Annual Management Summary.
• Develop, coordinate collection, and review of data associated with effectiveness, efficiency, and satisfaction of services.
• Ensure PYCSP Compliance with HR, CARF, AHCCCS, state and other regulatory body credentialing, supervision, and clinical competency requirements.
• Ensure health and safety activities, are implemented, at all PYCSP sites and ensure proper reporting and tracking of critical incidents, and quality of concerns.
• Oversee, investigate, adjudicate and document complaints/grievances and appeals.
• Track; submit monthly reports and prevention activities to AHCCCS.
• Track and submit quarterly reports on suicide surveillance and prevention activities to Indian Health Service.
• Assist with quarterly chart review process by responding to requests from AHCCCS for annual ICR; provide and/or update case review forms for program managers; tabulate and provide results from peer reviews; conduct psychiatry, closed file reviews, and report results.
• Coordinate all activities related to maintaining CARF accreditation (e.g. completing re-survey applications, maintaining on-going communication with CARF and preparations for re-surveys).
• Coordinate all activities related to preparation for annual AHCCCS Administrative review by following the review, completing, and submitting any required corrective action plan.
• Coordinate all activities related to preparation for licensing or licensing renewals for CSP Programs involving DOLS.
• Create and submit licensing documentation for future additional out-and inpatient programs to Policy and Procedure Committee; revise as recommended.
• Create, submit new procedures and standards for future additional out,-and inpatient program sites, as needed.
• As requested, assist Guadalupe Program Supervisor with any QM/UM activities specific to licensing by DOLS.
• Maintain and annually update procedures and standards pertinent to all future out and inpatient programs.
• Conduct HIPAA Trainings for all Health Division departments.
• Responsible for writing and submitting annual QM/UM Plan to AHCCCS.
• Manage, including the development of reciprocity agreements with the Regional Behavioral Health Authority (RBHA) and secure copies of those studies, setting-up training, as indicated by the results of those studies.
• Collaborate with Third Party Billing to document and capture all uncollected revenues due to documentation deficiencies.
• Document all deficiencies are on spreadsheets for tracking purposes.
• Ensure all missed revenues are collected or justification for inability to collect specific revenues are valid.
• Participate in the management team meetings and other meetings as requested.
• Chair the Revenue Cycle Audit Weekly Committee meetings.
• Identify and quantify findings of documentation deficiencies that result in lost revenues.
• Prepare and process requests for corrective actions for managers to remedy documentation deficiencies, oversee corrective activities by managers, and report findings to Senior Management.
• Conduct audits for Health Services Division departments, including but not limited to, the Pharmacy, New Beginning Nursing/Community Health Nursing, and Dental.
• Perform other duties of a similar nature or level as requested by supervisor or director.
  
  

Knowledge of:

• Complex federal, state, and tribal laws and regulations as they relate to Behavioral Health;
• Training requirements as dictated by CARF, AHCCCS and IHS requirements;
• CARF and AHCCCS Standards and Regulations;
• Supervise management principles and practices;
• Diagnostic criteria from the DSM -V, ICD-9 and ICD-10 ;
• Treatment planning and best practices regarding the utilization of different modalities of service;
• The PYBHP and AHCCCS Grievance process;
• Tribal, community and state behavioral health facilities;
• Yaqui culture, customs, resources and traditions and/or a willingness to learn.
  
  

Skills And Abilities

• Perform advanced mathematical/statistical calculations and data analysis;
• Read, analyze data, fiscal information, contracts and reports;
• Multi-task and track project goals;
• Computer use, including ClaimTrak, statistical and database software;
• Effective communication, both verbally and in writing;
• Clinical practice with Behavioral Health clients;
• Plan, organize and implement training activities;
• Develop professional reports, grants, proposals, policies and procedures;
• Interpret and comply with complex tribal, federal and state laws, rules, contracts and procedures;
• Develop and monitor automated tracking systems for various required activities; develop, organize and collect information on performance improvement indicators;
• Coordinate with program staff to implement QM/UR activities;
• Track, analyze and trend information; formulate conclusions and recommendations to management team;
• Design and distribute various survey instruments; analyze results and present outcomes;
• Quickly adjust priorities or procedures to accommodate changes;
• Establish and maintain effective working relationships with employees, other public agencies and people from various socioeconomic backgrounds;
• Maintain confidentiality of information;
• Provide oversight of the client grievance process;
• Meet program, grant and contract deadlines in a timely fashion;
• Problem-solve complex situations;
• Schedule and facilitate QM/UR activities and meetings;
• Operate a variety of office equipment, including a computer and related software applications;
• Good communication and interpersonal skills as applied to interaction with co-workers, supervisor, management, Council members, and the public. Have ability to sufficiently exchange or convey information and receive verbal and written work instructions.
  
  

Master's Degree in Behavioral Health or related field plus three (3) years of Quality Management/Utilization Review or related experience;

AND

• Behavioral Health Clinical knowledge, skills, abilities and experience;
• Bilingual in English/Spanish preferred.
  
  

Special Requirements:

• Must possess and maintain a valid Arizona Driver's License.
• This position will require the incumbent to work non-traditional hours, nights, and weekends;
• Must have a current Level 1 Arizona Clearance Card or be able to obtain the Level 1 Arizona Clearance Card within ninety (90) days of hire. Failure to maintain a current Level 1 Clearance Card will result in removal from this position.