Utilization And Continuous Quality Improvement Manager

The Utilization and Continuous Quality Improvement Manager is responsible for the evaluation of services delivered to clients and agency processes to ensure that services delivered are consistent with funding requirements, best practices, provider contracts and federal/state rules and regulations. The UCQIM would develop, implement, and conduct statistical analyses of projects, studies, and evaluations designed to improve the quality of services and internal processes under the umbrella of the 1115 SUD and BH waivers. The UCQIM would perform utilization management to ensure continuity of care and that clients receive the right service, at the right time, at the right frequency. This would be through the performance of prior authorization review, continued stay and discharge reviews for behavioral health services. The UCQIM assists the Chief Clinical Officer with performing all aspects of data analysis, preparing accurate reports through the creation of professional charts and data reports. Project Management background will allow for the shifting between macro and micro level planning, maintaining both the big picture and seeing that the details are covered. Position can be onsite or remote.

Utilization Management Responsibilities:

• Conducts chart reviews of instances of care authorized for utilization purposes, case reviews for individuals that are identified as either over or under-utilizers of services.
• Utilizes clinical knowledge in a range of developmental disabilities diagnoses for children and adults to facilitate clinical decisions based on the established Utilization Management Guidelines as well as general knowledge, clinical skills, utilization trends, best/promising practice research in developmental disabilities and/or co-occurring mental illness, person-centered planning, client rights, and responsibilities, assessments, legal requirements, clients’ needs, and available community resources.
• Conducts routine and targeted utilization review of services to ensure requests for services in established target populations receive services in the least restrictive, most integrated setting appropriate to their individual clinical needs and for reviewing the utilization of approved service(s) post-delivery.
• Responsible for providing technical assistance to the provider network and assisting in the identification of the most clinically appropriate treatment options.
• Responsible for the tracking and processing of staff to meet the qualifications to become a Qualified Addictions Professionals (QAP).
• Responsible for documentation and clinical protocols for utilization purposes and case reviews for individual clients to conduct chart reviews.
• Responsible for providing linkage, authorizations, and level of care determinations to providers, assisting providers with creative problem solving to suggest alternative approaches to care.
• Development of letters that communicate to enrollees and providers the reason for any adverse decision and offers information regarding the options to appeal any adverse decision.
• Attends internal and external meetings and training as needed to stay informed of changes in local, State, Federal and Division requirements.
• Utilizes established systems to verify client eligibility, treatment history, and other data as needed for authorization reviews.
• Maintaining and updating of client admission and discharge lists, caseload rosters, and other program tracking and data forms.
• Demonstrate an extensive understanding of the Diagnostic and Statistical Manual of Mental Disorders (current version) and have considerable knowledge of the MH/SU/I/DD service array.

Quality Improvement Responsibilities:

• Responsible for assessing and improving clinical quality outcomes for clients and applying clinical knowledge and analytical skills to effectively and efficiently complete quality activities and improve performance metrics.
• Works within a team and utilizes identified clinical quality trends and improvement opportunities to develop interventions aimed at improving client outcomes.
• Demonstrates a comprehensive knowledge of mental health and appropriate treatment for major diagnostic categories, behavioral health principles, techniques, and practices, and their application to complex treatment and service provisions.
• Demonstrates knowledge of person-centered and recovery philosophies, interventions, and assessments for mental health, developmental disability, and substance use disorders.
• Responsible for providing data integrity and management and organizational and project support.
• Assists in developing and delivering instructional materials and providing technical assistance related to quality reviews, data analysis, and reporting.
• Serves as team leader for chart or clinical reviews of consumer information to conduct analysis of program effectiveness or to identify opportunities for process or quality improvement.
• Provide ongoing consultation and training of behavioral health staff.
• Conduct quarterly tracking of clinical performance measures as part of the Akeela’s Analytic unit.
• Provide ongoing electronic health record support as a system administrator.
• Serve as an active member on the compliance committee.
• Orient and train new staff members, as necessary.
• Perform other duties as assigned.

Essential Skills-Any Equivalent Combination Of Knowledge, Skills, Abilities, Education & Experience:

• A Master’s degree in a Human Services field (such as Psychology, Social Work, Counseling etc.) is required, along with at least two years of post-degree progressive experience providing similar services to the population served.
• A valid Alaska licensure from a behavioral health licensure board such as a LCSW, LPA, LMFT, LPC.
• 2 years post-degree progressive experience in the field of mental health, intellectual developmental disabilities or substance use is preferred.
• Experience in Utilization Management is preferred.
• Experience completing clinical reviews, compliance reviews, and preparing written reports is preferred.
• Experience in quality improvement, analysis, development, public health, or related area is preferred.
• Proficiency in Microsoft Office products (such as Word, Excel, Outlook, PowerPoint, etc.) and Adobe Acrobat is preferred.
• Ability to handle the position without continual supervision.
• Ability to supervise clinical staff members.
• Ability to function under stress.
• Ability to function and communicate effectively in an interdisciplinary team.
• Ability to deal with hostile or distraught clients of all age levels and with their family members.
• Ability to read, write and speak English.