Quality Assurance Reviewer
Alliant Health Group
400 Arbor Lake Dr Suite B-800
Columbia, SC 29223
The Quality Assurance Reviewer, as a member of a professional multi-disciplinary work team, is responsible for the quality assurance reviews and monitoring of policy compliance for the SC DDSN Quality Assurance Review program. They conduct case review activities including record review, observation and evaluation of Residential Habilitation and Day Services, reviews of providers’ plans of correction, follow-up reviews and special circumstance reviews. They conduct consumer interviews.
ESSENTIAL JOB FUNCTIONS
· Perform desk review through analysis and review of previous review findings and begins case activity log in developing the appropriate approach for the on-site review.
- Conduct on-site reviews for the specified SC DDSN providers which includes some but not all of the following: exit and entrance sessions with the appropriate management and clinical staff from the provider location, staff interviews, and document(s) review.
- Notify providers in advance of upcoming on-site visit. Conducts entrance and exit interviews with providers informing them of purpose of visit and preliminary findings.
- Make recommendations based on professional judgment and experience for the compliance with SC DDSN standards, the necessity/quality of the services and the appropriateness of the setting while substantiating recommendations with clinical rationale.
- Analyze, interprets and documents appropriate determination review outcomes utilizing the MedGuard review system.
- Prepare timely, accurate, written letters/reports to providers/SC DDSN on initial on-site and follow-up desk/on-site review findings.
- Review additional information related to requests for follow-up reviews after initial findings and makes a recommendation based on professional judgment and experience for the compliance with SC DDSN standards, the necessity/quality of the service and the appropriateness of the setting.
- Serve occasionally on panel of peers to provide professional expertise regarding standards of service delivery.
- Performs other duties assigned
KNOWLEDGE, SKILLS AND ABILITIES
· Strong organizational skills with ability to demonstrate the work priorities. Strong theoretical clinical knowledge base and problem-solving skills.
- Strong organizational skills with ability to demonstrate the work priorities.
- Demonstrate ability to perform work with considerable independence by use of creative thinking, thorough analysis of problems, and use of innovative approaches to problem resolution.
- Moderate computer skills (Excel and Word) including word-processing (30-50 WPM) and data entry skills required.
- Excellent interpersonal, written and verbal communication skills required.
- Excellent telephone skills, including ability to handle difficult calls/callers.
· Able to travel as needed driving and/or going on airplane to customer locations or meetings
EDUCATION, EXPERIENCE, AND TRAINING
- Licensed Registered Nurse (Current South Carolina license required)
- Bachelor of Science in Nursing (BSN) and/or Master of Social Work (MSW) with a current South Carolina license as a Licensed Clinical Social Worker (LCSW) or related human services degree preferred
- 3 to 5 years clinical experience working with individuals with developmental disabilities required.
- Previous SC DDSN, Medicaid, Utilization Review, Case Management, Quality Assurance, Claims Auditing or Fraud/Abuse experience required.