GENERAL PURPOSE:
Functions as Assertive Community Treatment (ACT) Utilization Reviewer in accordance with Office of Mental Health (OMH) regulatory requirements, Utilization Reviewer as retrospective for Medicaid routine audit and documentation compliance audit, billing denials, and Medicare Targeted Probes. External agency collaboration for triage management of psychiatry high risk-high acute services utilizers. Functions as a project coordinator and QA support for Psychiatry. Collaborates with clinical leadership team using data for ongoing monitoring and evaluation of patient care, coordination of record management and performance improvement. Functions on CRMQIT including team project management, process improvement and policy/practice change, data aggregation. Collects, validates, integrates information, and disseminates to Quality Assurance Administrator and Psychiatry Quality Steering committee. Provides support functions for IRC meetings, safety committees and special projects as assigned. Special QA/QI project support as assigned.
RESPONSIBILITIES:
Utilization Review data analysis and reporting:
Primary coordinator of utilization review for Part 599 OMH clinics. Identify trends across the department, verify goal achievement and service quality, and identify areas of improvements and the impact of corrective actions. Program analysis includes core outcomes at 6-month intervals consistent with the required assessment and service planning process. Data will be disseminated to inform decision making regarding improvement of departmental performance. Analysis will be used as a bench measure for teams to review their progress in achieving core outcomes and to make decisions regarding the improvement of organizational performance.
ACT Client Utilization Review:
Primary coordination of systematic monitoring of performance of the ACT team in assisting recipients to achieve their treatment outcomes. This will include the development of a quality improvement plan consistent with the mission and values of the ACT program that is maintained ongoing basis. Additionally, verifies service provision and quality that supports goal attainment, identification of service provision and treatment which needs improvement, Corrective action/process improvement plans specific to the results of the analysis, and Self-administration of the DACTS annually to ensure fidelity to the ACT model and transmittal of this information to OMH. Primary development and participation in any state or LGU utilization management process.
Data collection for treatment outcomes (ACT):
Primary manager of data collection process that provides information relevant to specific treatment outcomes. This includes ensuring completion of forms provided by NYSOMH on the CAIRS System for a baseline assessment (BASF), to be begun within 30 days of admission and completed in a timely manner, and updated assessments (FUAF) at 6-month intervals, to assess recipient outcomes. These forms are to be completed through the CAIRS system. These forms will be part of the team’s regular assessment and service planning process that will be monitored prospectively.
Medicaid Routine Audits:
Develops audit filters for routine, ongoing Medicaid documentation compliance audit. Performs monthly, random chart reviews for Presence/quality of required documentation elements. Develops trend reports Quality Steering Committee notification and disseminated at Ambulatory Leadership Meeting and Inpatient Staff meetings as indicated.
Regulatory and Accreditation agency audit:
Performs Monthly, random chart reviews for presence of documentation that supports Office of Mental Health (OMH) Performance Improvement Plans (PIP) and Joint Commission Corrective action plans have been satisfied as it relates to documentation standards/requirements and identifies that corrective actions have sustained change.
Develops trend reports Quality Steering Committee notification and disseminated through Ambulatory Leadership Meeting and Inpatient Staff meetings as needed
External Agency/CMS Audits:
Performs chart reviews and complies documentation for audits including but not limited to: Office of Medicaid Inspector General (OMIG), Office of Inspector General (OIG), Health Management Systems (HMS), and CMS TPE audits. Compiles result and analyzes for trends in lack of compliance with documentation requirements.
QUALIFICATIONS:
- Bachelor’s degree with major course work in an appropriate health, social or technical field required
- 3-5 years of related experience; or an equivalent combination of education and experience required.
- Highly skilled and knowledgeable in EPIC system. Strong communication and interpersonal skills. Self-directed with strong organizational skills required.
- License in mental health profession required
The University of Rochester is committed to fostering, cultivating, and preserving a culture of equity, diversity, and inclusion to advance the University’s mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion/creed, sex, sexual orientation, citizenship status, or any other status protected by law. This commitment extends to the administration of our policies, admissions, employment, access, and recruitment of candidates from underrepresented populations, veterans, and persons with disabilities consistent with these values and government contractor Affirmative Action obligations.
