11/19/2008 43390

DIRECTOR, BUREAU OF QUALITY MANAGEMENT AND DATA REVIEW

DEFINITION: This is professional managerial work directing the activities of the Bureau of Quality Management and Data Review in the Office of Mental Health and Substance Abuse Services (OMHSAS), Department of Public Welfare.

The employee in this job directs the development, analysis, and implementation of policies for the quality management, data analysis and utilization review functions of the Bureau. The employee oversees policy development and implementation related to quality management systems utilized by mental health and substance abuse service providers. The employee also directs the utilization review of fee-for-service authorization requests by mental health clinical service providers, ensures appropriate application of federal and state requirements, and directs the development of continuity of care agreements between state mental hospitals and community mental health programs. The employee manages data collection, analysis, and reporting for use in program planning, monitoring, and resource allocation. Work is assigned in the form of broad objectives and policy statements, and the employee exercises considerable freedom in the rendering of technical and administrative decisions. Work is reviewed for soundness and completeness of the recommendations, conformance to broad objectives and policy statements, and effectiveness of results.

EXAMPLES OF WORK: Directs the policy development, implementation, and assessment of the quality of behavioral health programs and services impacting continuous quality management processes, quality improvement, data collection and reporting, and data monitoring.

Directs the development of all policy related to quality management programming, information system design and implementation, and utilization review activities.

Develops and implements systems, policies, and procedures for data collection, analysis, and reporting of quality and utilization activities from contracted mental health and substance abuse providers.

Develops and implements a quality management work plan that measures performance and quality of contracted and state administered mental health and substance abuse services provided by community-based managed care organizations and state mental health hospitals.

Directs the review, analysis, and evaluation of existing and proposed federal and state legislation to determine the impact on mental health and substance abuse service provision, quality and utilization.

Manages the Behavioral Health Fee-for-Service Utilization Review processes.

Establishes procedures to ensure contractor compliance with state and federal regulations regarding the delivery of mental health and substance abuse services.

Oversees the development and maintenance of OMHSAS information technology systems.

Coordinates system design changes for processing claims through the Provider Reimbursement and Management Information System (PROMISe) with the Office of Medical Assistance Programs.

Develops and implements policies and procedures for HealthChoices provider enrollment and claims management.

Identifies best practices, gaps and problems in service delivery and opportunities for improvement.

Directs the monitoring of the managed care complaint, grievance, and appeal process in the HealthChoices programs.

Reviews and assesses consumer and family complaints regarding services provided by the mental health service system.

Directs the review of denial decisions made by managed care organizations to ensure consistency with regulatory requirements.

Represents OMHSAS on statewide workgroups and committees.

Performs the full range of supervisory duties.

Participates in the performance of subordinates’ work consistent with operational or organizational requirements.

Performs related work as required.

KNOWLEDGE, SKILLS AND ABILITIES: Knowledge of principles, practices, and methods in quality assessment, monitoring, and evaluation of behavioral health programs and services.

Knowledge of the clinical practices and methods utilized to determine medical necessity, cost effectiveness, and adequacy of behavioral health programs and services.

Knowledge of functions, programs, resources, and requirements related to behavioral health programs and services.

Knowledge of principles and practices of data collection, analysis, and reporting.

Knowledge of the principles and practices of policy and program planning, development, and implementation.

Ability to interpret medical and other health data.

Ability to read, analyze, and interpret policies, procedures, and regulations.

Ability to establish and maintain effective working relationships.

Ability to communicate effectively in writing.

Ability to communicate effectively orally.

MINIMUM EXPERIENCE AND TRAINING: Seven years of professional experience in behavioral health programs which includes four years in a managerial, consultative, or administrative capacity involving planning and coordinating the development and implementation of behavioral health programs and policies; and a bachelor’s degree;

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An equivalent combination of professional experience and training which includes four years in a managerial, consultative, or administrative capacity involving behavioral health programs and policies.