Human Service Professional - Medicaid Quality Assurance Specialist

The Medicaid Quality Assurance Specialist reviews Medicaid related services within the Behavioral Health Division of the Department of Health and Human Services (HHS) for the purposes of identifying client, staff and systems errors that may result in improper billings to third parties, incorrect benefits to clients, and sometimes, fraudulent activities (intentional program violations by the client, provider, or staff member).  The Medicaid Quality Assurance Specialist also helps to train Division staff and contract providers to avoid Administrative Code
errors, incorrect billings, and to ensure general quality assurance.

• The following duties are most critical for this position.  These are not to be construed as exclusive or all-inclusive.  Other duties may be required and assigned.
• Maintains knowledge of Federal and State rules, regulations and Administrative Codes that impact Medicaid. Trains staff to recognize and correct errors and ensure program compliance and accuracy.
• Performs Quality Assurance reviews on cases and contract provider records for compliance with Federal, State, and department policies, procedures and Administrative Codes. Analyzes the results of reviews and works with department staff on assisting with implementing corrective measures.
• Develops and maintains resources, networks with outside agencies and attends necessary training in order to maintain current knowledge of all rules and regulations enacted by Federal, State and local entities for Medicaid.
• Identifies and assists in developing improvement strategies for Medicaid programs and monitors results of implementation of those improvement strategies. Ensures that a continuous improvement process is maintained in the department for all Medicaid programs.
• Maintains regular and predictable attendance and maintains all necessary documentation and evidence in compliance with audit and statutory requirements.
• Effectively facilitates meetings with leadership, management, and staff on the analysis of performance including: Identification of challenges, achievement, and compliance with established guidelines and best practice standards.
• Participates actively and effectively in development activities such as conference calls, professional meetings to include MH/AODA and Fiscal related Statewide and Regional meetings. Completes and maintains necessary documentation and reports according to applicable requirements, Codes and policies.
• Participates in unit and department-wide meetings, discussions, training, and activities, demonstrating orientation toward professional competence and continuous quality improvement; makes recommendations for and assists with service improvement when warranted.
• Performs other duties as assigned.

• A minimum of a bachelor’s degree from an accredited college or university in a closely related field preferred. Relevant prior experience with the population(s) to be served preferred.
• Two years experience in direct practice with individuals with a range of mental health and/or substance abuse diagnoses preferred.
• Experience in MH/AODA service facilitation and MH/AODA Administrative Codes.
• Experience in Quality Assurance practice preferred.
• Case Management experience preferred.
• Displays a high level of initiative, effort and commitment towards completing assignments efficiently and accurately. Works well in independent project development and adapts easily to multiple projects, assignments, and deadlines.
• Knowledge and understanding of federal laws, State statutes, and administrative rules which regulate the services provided.
• Ability to coordinate activities and functions that cross unit and departmental lines and involve other County and community agencies.
• Ability to establish and maintain effective working relationships with coworkers, superiors, community partners, and the public at large.
• Ability to relate to people and to communicate effectively in both written and oral formats.
• Ability to maintain confidentiality. 
• Ability to exercise sound judgment in confrontational and stressful situations.
• Ability to follow instructions, to complete tasks, and to work closely with the supervisor and others.

• Frequent contact with co-workers, consumers, State and County personnel, other authorities, community partners, and members of the public.
• May occasionally deal with aggressive or violent individuals.

• Work is generally performed in a standard office setting with occasional need to provide services in other locations. There may be travel to a variety of community and/or regional locations.
• Ability to lift up to 20 pounds and a combination of sitting and standing postures may be required. Ability to minimally work 8 hours per day and 40 hours per week is required.
• Must be able to operate and be conversant with office equipment including phone, computer, facsimile , calculator, printer and photocopier. Familiarity and capacity to work with various software applications and keyboarding proficiency are essential.