DSNP Quality Assurance Specialist

DSNP Quality Assurance Specialist

Requirements

• High School Diploma/GED required
• Bachelor degree preferred or relevant experience in lieu of degree
• Requires a minimum of 3 years experience in the health care delivery system/industry
• Prefers three (3) years managed care experience in a customer-oriented capacity
• Requires experience in chart reviews, indicators and databases
• Working knowledge or regulatory agency standards and requirements desired
• Requires quality initiative experience

Responsibilities

• Responsible for conducting audits on member charts, including assessments (at least quarterly) for all areas of MLTSS/DSNP care management operations, which review daily business practice compliance to regulatory requirements relative to the State Medicaid Contract funded in part by the Centers for Medicare and Medicaid Services (CMS)
• Analyzes, prepares, documents and distributes audit reports/outcomes, including error trends, to the MLTSS/DSNP Department management for follow-up with care management staff; and conducts follow up reviews of corrective action
• Comprehensively collaborates with the MLTSS/DSNP Department to review outcomes and then develop process improvement recommendations and changes as well as the need for and provision of continuous education/training opportunities
• Presents MLTSS/DSNP Quarterly Audit and other Targeted Audit Reports and supporting findings during MLTSS/DSNP Subcommittee meetings of which the MLTSS Medical Director and other Directors are voting members
• Organizes and prioritizes multiple projects within MLTSS/DSNP oversight activities, under the direction of the MLTSS/DSNP Manager, and communicates internally, with the MLTSS/DSNP Department and the Quality Management Department, as well as externally through attendance at State quality meetings, to recognize MLTSS program-wide improvement initiatives and participate in the implementation of strategies to improve the MLTSS/DSNP Program within HNJH
• Conducts periodic targeted audits of various components of the MLTSS/DSNP program, against business process flows in order to evaluate compliance with MLTSS/DSNP standards
• Responsible for collaborating with Analytic staff in the development of MLTSS/DSNP tool(s). These efforts include testing the audit tool, communicating feedback, and ensuring timelines are established and met
• Develops/Assists with creating internal workflows to establish standardized guidelines for audits and other internal processes

Preferred Qualifications

• Preferred Licensed Registered Nurse
• Prefers knowledge of managed care principles
• Prefer exposure to data compilation and presentation processes