Quality Assurance Reviewer, SCDDSN

Alliant Health Group is a family of companies that provides professional services supporting the effective administration of healthcare programs and funding to support healthcare improvement initiatives. Alliant Health Solutions provides Federal and state government entities with the services, expertise and information systems necessary to increase the effectiveness, accessibility and value of health care.

Currently, Alliant Health Solutions, a "2024 Best Place to Work and Healthiest Employer", seeks a Quality Assurance Reviewer. The Quality Assurance Reviewer, as a member of a professional multi-disciplinary work team, is responsible for the quality assurance reviews and monitoring of policy compliance for the South Carolina Department of Disabilities and Special Needs (SC DDSN) Quality Assurance Review program. They conduct case review activities including record review, observation and evaluation of Residential Habilitation and Day Services, reviews of providers' plan of correction, follow-up reviews and special circumstance reviews. They also conduct consumer interviews.

In this role, the ideal candidate will:

• Perform desk review through analysis and review of previous review findings and begins case activity log in developing the appropriate approach for the on-site review.
• Conduct on-site reviews for the specified SC DDSN providers which includes some but not all the following: exit and entrance sessions with the appropriate management and clinical staff from the provider location, staff interviews, and document(s) review.
• Notify providers in advance of upcoming on-site visits. Conducts entrance and exit interviews with providers informing them of purpose of visit and preliminary findings.
• Make recommendations based on professional judgment and experience for the compliance with SC DDSN standards, the necessity/quality of the services and the appropriateness of the setting while substantiating recommendations with clinical rationale.
• Analyze, interpret, and document appropriate determination review outcomes utilizing the MedGuard review system.
• Prepare timely, accurate, written letters/reports to providers/SC DDSN on initial on-site and follow-up desk/on-site review findings.
• Review additional information related to requests for follow-up reviews after initial findings and makes a recommendation based on professional judgment and experience for the compliance with SC DDSN standards, the necessity/quality of the service and the appropriateness of the setting.
• Occasionally serve on panel of peers to provide professional expertise regarding standards of service delivery.

Other Job Functions:

• Work in close collaboration with other team members to support the development of new projects and the continuous improvement of the overall work of the team.
• Promote core values of teamwork, professionalism, effective communication skills and positive behavior.
• Maintain security and confidentiality of all information in accordance with HIPAA (Health Insurance Portability and Accountability) laws and regulations and company policies.
• Demonstrate compliance with company corporate and departmental policies as evidenced by attendance, punctuality, and dress.
• Perform other duties as assigned.

Knowledge, skills and abilities required for this role include:

• Strong theoretical clinical knowledge base and problem-solving skills.
• Strong organizational skills with ability to demonstrate work priorities.
• Demonstrate ability to perform work with considerable independence by use of creative thinking, thorough analysis of problems, and use of innovative approaches to problem resolution.
• Moderate computer skills (Excel and Word) including word-processing (30-50 WPM) and data entry skills.
• Excellent interpersonal, written, and verbal communication skills.
• Excellent telephone skills, including ability to handle difficult calls/callers.
• Computer literate
• Ability to travel by car or plane to Company locations, customer meetings or other locations as needed.

Education, experience and training required and preferred for the position are below:

Required:

• Bachelor's degree in social work, Sociology, Psychology, Nursing (BSN) or other Human Services degree
• A minimum of 3 years of previous SC DDSN, Medicaid, Mental Health Utilization Review, Case Management, Quality Assurance, Claims Auditing, and/or Fraud/Abuse experience

Preferred:

• Registered Nurse or Social Worker with current and unencumbered South Carolina license
• Previous clinical experience working with individuals with developmental disabilities

Alliant offers work/life balance and great benefits including medical, dental life, disability, paid-time off, retirement with match and contribution, disability, employee assistance program, parental life, and more. If interested, click the apply icon above to apply.
If you are limited in the ability to access or use this online application process and need an alternative method for applying, we will determine an alternative method for you to apply. Please contact 678-527-3000.