Clinical Quality Analyst

This is a fully remote position, open to applicants in North Carolina.

📋 Description

• Evaluate Care Management documentation and activities to guarantee adherence to compliance standards.

• Assess the quality of Care Management internal processes/plans and provider information, including Person-Centered Plans and chart notes, to ensure they align with established procedures and best practices.

• Conduct audits of Care Management clinical documentation, case interventions, and, when available, staff phone recordings, ensuring consistency with program descriptions, workflows, internal policies, evidence-based clinical guidelines, NCQA guidelines, CMS guidelines, and applicable regulatory standards.

• Recognize and escalate issues that may present quality, compliance, and safety risks that could negatively impact business operations.

• Assess the clinical appropriateness of decisions, recommendations, and actions documented within Care Management.

• Analyze both qualitative and quantitative data to accurately document findings.

• Propose improvements based on the records reviewed and compile detailed reports of findings.

• Identify systemic and/or operational challenges that impede achieving quality performance standards as established by NCQA, as well as relevant state and federal laws and regulations.

• Analyze data and report on findings.

• Create monthly Care Management Quality reports on staff performance for submission to Directors, Managers, and Supervisors.

• Provide written feedback to Directors, Managers, and Supervisors regarding quality concerns related to individual performance, compliance risks/trends, root cause analysis, and recommended system or process enhancements.

• Assess staff knowledge gaps and coordinate training initiatives.

• Collaborate with Care Management Leadership to align learning and training opportunities with the Care Management Training team.

• Monitor the effectiveness of staff training and its impact on outcomes resulting from enhanced training.

⛳️ Requirements

• Graduation from an accredited nursing school with a Registered Nurse (RN) license and three (3) years of experience in care management for individuals in populations such as Traumatic Brain Injuries (TBI), Intellectual/Developmental Disabilities (I/DD), Mental Health/Substance Use Disorders (MH/SUD), Severe Mental Illness (SMI), or Physical Health (PH).

• Alternatively, a Master’s degree in Health, Psychology, Sociology, Social Work, or another relevant Human Services field from an accredited college/university with a North Carolina Clinical license (LCSW, LCMHC, LMFT, LPA) and three (3) years of experience in care management for individuals in the same populations.

• Required experience includes familiarity with care plans, comprehensive assessments, care management interventions, and service engagement activities.

• Experience with Medicaid Managed Care Integrated care (behavioral and physical health) is required.

• Preferred experience includes auditing clinical documentation.

• Preferred certification: Certified Care Manager (CCM).

• Special requirement: A current, active, unrestricted NC clinical license such as RN, LCSW, LMHC, or LMFT to practice as a health professional within the scope of licensure in North Carolina.

• Knowledge, Skills, & Abilities: Understanding of North Carolina State and Federal rules and requirements related to the service continuum; familiarity with Tailored Plan, Integrated Care, and Care Management processes and regulatory requirements; knowledge of best practices for behavioral & physical health and/or intellectual/developmental disabilities; proficiency in Microsoft Excel, Word, PowerPoint, SPSS, and Survey Monkey (or similar online survey tools); strong clinical and problem-solving skills; effective interpersonal and analytical skills; adept conflict resolution and diplomacy skills; and excellent communication abilities with a capacity to negotiate and resolve issues with minimal assistance.

🏝️ Benefits

• Medical

• Dental

• Vision

• Life

• Long Term Disability

• Generous retirement savings plan

• Flexible work schedules, including hybrid/remote options

• Paid time off, including vacation, sick leave, holiday, and management leave

• Dress flexibility