CSP Utilization Review Specialist/Quality Manager

Job Summary

Under general direction, of the Associate Administrative Director of Centered Spirit, the Utilization Review Specialist/Quality Manager is responsible for coordinating the implementation of the quality management/utilization review systems and activities of the Pascua Yaqui Centered Spirit Program (PYCSP).

Principle Duties and Responsibilities

• Cook up a wide range of quality management/utilization review functions including information management, outcomes management, utilization review, policy and procedure, development/monitoring, report activities as required by AHCCCS, CARF, Indian Health, and Yoeme Health Services.
• Co-Chair quarterly Quality Management/Utilization Review Committee meetings.
• Provide training to all staff in the area of Quality and Improvement.
• Develop and implement the PYCSP Strategic Plan for Performance Improvement.
• Track outpatient service utilization provided by PYCSP for all clients (including those identified as SMI or SED), for days of stay at inpatient and residential facilities; ensure outpatient facilities meet state requirements concerning IMD placements.
• Write and distribute quarterly PYCSP reports and Annual Management Summary.
• Develop, coordinate collection, and review of data associated with effectiveness, efficiency, and satisfaction of services.
• Ensure PYCSP Compliance with HR, CARF, AHCCCS, state and other regulatory body credentialing, supervision, and clinical competency requirements.
• Ensure health and safety activities, are implemented, at all PYCSP sites and ensure proper reporting and tracking of critical incidents, and quality of concerns.
• Oversee, investigate, adjudicate and document complaints/grievances and appeals.
• Track; submit monthly reports and prevention activities to AHCCCS.
• Track and submit quarterly reports on suicide surveillance and prevention activities to Indian Health Service.
• Assist with quarterly chart review process by responding to requests from AHCCCS for annual ICR; provide and/or update case review forms for program managers; tabulate and provide results from peer reviews; conduct psychiatry, closed file reviews, and report results.
• Cook up all activities related to maintaining CARF accreditation (e.g. completing re-survey applications, maintaining on-going communication with CARF and preparations for re-surveys).
• Cook up all activities related to preparation for annual AHCCCS Administrative review by following the review, completing, and submitting any required corrective action plan.
• Cook up all activities related to preparation for licensing or licensing renewals for CSP Programs involving DOLS.
• Create and submit licensing documentation for future additional out-and inpatient programs to Policy and Procedure Committee; revise as recommended.
• Create, submit new procedures and standards for future additional out,-and inpatient program sites, as needed.
• As requested, assist Guadalupe Program Supervisor with any QM/UM activities specific to licensing by DOLS.
• Maintain and annually update procedures and standards pertinent to all future out and inpatient programs.
• Conduct HIPAA Trainings for all Health Division departments.
• Responsible for writing and submitting annual QM/UM Plan to AHCCCS.
• Manage, including the development of reciprocity agreements with the Regional Behavioral Health Authority (RBHA) and secure copies of those studies, setting-up training, as indicated by the results of those studies.
• Cook up with Third Party Billing to document and capture all uncollected revenues due to documentation deficiencies.
• Document all deficiencies are on spreadsheets for tracking purposes.
• Ensure all missed revenues are collected or justification for inability to collect specific revenues are valid.
• Participate in the management team meetings and other meetings as requested.
• Chair the Revenue Cycle Audit Weekly Committee meetings.
• Identify and quantify findings of documentation deficiencies that result in lost revenues.
• Prepare and process requests for corrective actions for managers to remedy documentation deficiencies, oversee corrective activities by managers, and report findings to Senior Management.
• Conduct audits for Health Services Division departments, including but not limited to, the Pharmacy, New Beginning Nursing/Community Health Nursing, and Dental.
• Perform other duties of a similar nature or level as requested by supervisor or director.

Required Knowledge, Skills, and Abilities

• Knowledge of: - Complex federal, state, and tribal laws and regulations as they relate to Behavioral Health;
• Training requirements as dictated by CARF, AHCCCS and IHS requirements;
• CARF and AHCCCS Standards and Regulations;
• Supervise management principles and practices;
• Diagnostic criteria from the DSM -V, ICD-9 and ICD-10 ;
• Treatment planning and best practices regarding the utilization of different modalities of service;
• The PYBHP and AHCCCS Grievance process;
• Tribal, community and state behavioral health facilities;
• Yaqui culture, customs, resources and traditions and/or a willingness to learn.

Education, Certifications and Experience Required

• Master's Degree in Behavioral Health or related field plus three (3) years of Quality Management/Utilization Review or related experience; AND- Behavioral Health Clinical knowledge, skills, abilities and experience;
• Bilingual in English/Spanish preferred.

Additional Information

• This position will require the incumbent to work non-traditional hours, nights, and weekends;
• Must have a current Level 1 Arizona Clearance Card or be able to obtain the Level 1 Arizona Clearance Card within ninety (90) days of hire. Failure to maintain a current Level 1 Clearance Card will result in removal from this position.

Contact Information

• Employer: Pascua Yaqui Tribe
• Address: 7474 S. Camino De Oeste, Tucson, Arizona, 85757
• Phone: (520) 883-5040
• Website: http://www.pascuayaqui-nsn.gov