This position is responsible for teaming with agency staff and leadership in planning and conducting QA/QI activities for his/her assigned programs. The Outcome & Evaluation Specialist – Medicaid is responsible for ensuring compliance with contract/grant terms, licensing, certification and accreditation standards, and compliance with external reviews and required program improvement plans. In addition, he/she is responsible for the ongoing collection and review of performance, utilization and fiscal data relative to each assigned service/contract; facilitating and guiding QA/QI efforts and corrective action plans when there is an opportunity or clear need for improvement.
The Outcome & Evaluation Specialist – Medicaid leads regular utilization reviews to assess quality of services and consistency of documentation against standards, provides on-going training and technical assistance to program staff, and ensures community-based mental health services are reasonable and necessary with treatment modalities specifically designed to meet individualized needs of each client.
In addition to the QI Director, this position works closely with the Clinical Vice President and programs under her direction including: Residential therapy services, Foster Care Clinical services, and Behavioral Health Services. The position is supervised by the QI Billing Analyst.
Day to Day – the Outcome & Evaluation Specialist – Medicaid will partner with his/her assigned program leadership, serving as a “point of contact” and subject matter expert for all QA/QI functions. Duties to include use of agency data sources to extract and manipulate data for performance measurement/outcomes monitoring; leading quarterly file review / utilization review process, documenting issues of compliance and implementing projects for the purpose of improvement of programs/processes. The Outcome & Evaluation Specialist – Medicaid will work with the QI team and agency committees as assigned to assure consistency across the agency and delivery of high quality services with an eye on improvement at all times.
The Outcome & Evaluation Specialist – Medicaid must demonstrate a strong working knowledge of DCFS Rule 132 and HFS Rule 140 in day to day job functions. Prevention of fraud, waste and abuse is essential as the Outcome & Evaluation Specialist – Medicaid leads regular Utilization Reviews to assess quality of services and consistency of documentation against the standards. This position also provides on-going training and technical assistance to program staff, ensuring uniform documentation across programs.
A strong Outcome & Evaluation Specialist – Medicaid will be able to work individually as well as collaboratively with the QI team and other agency programs. A strong solution-oriented, strengths-based approach is needed in order to communicate and implement ongoing quality improvements and effectively work with other parts of the agency. This position requires an ability to evaluate compliance and quality, and proactively identify/recommend potential improvements based upon results.
Job Function:
The Outcome & Evaluation Specialist – Medicaid actively supports and implements high quality outcomes and continuous quality improvement within the agency. This position works closely with the Director to monitor and measure performance of community-based mental health services against regulatory compliance and contractual obligations.
Education and Experience: - Minimum Bachelor’s degree in Human Services or related field - Experience with quality control / compliance preferred - Knowledge and experience with Medicaid Rule 132/140 strongly preferred - Demonstrated ability to analyze and communicate data and complex topics effectively to various audiences
Skill Requirements: - Strong problem-solving, analytical, interpersonal and customer service skills - Excellent organizational skills and attention to detail are a must - Strong written and oral communication skills - Ability to work independently and as an active team member - Maturity and sensitivity to cultural and individual differences - Ability to handle job related matters in a professional, diplomatic and confidential manner - Proficient in utilizing office systems and equipment - Experience with Internet research and outcomes measurement - Experience with computer software programs such as Access, Excel, Word, PowerPoint, TIER/Electronic Medical Record system
Physical Requirements: - Speaking and hearing ability to allow for effective oral communication of information - Ability to transport self and others to various meetings - Physical and emotional stamina to handle job related stress
Benefits & Pay:
