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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00206732 |
Description Activated On: 1/15/2026 8:57:20 AM |
Position Purpose: Describe the primary purpose of this position and how it contributes to the organization’s objectives. Example: Provides clerical and office support within the Division to ensure its operations are conducted efficiently and effectively. This Quality Assurance/Risk Management Coordinator position is integral in the fulfillment of the Commonwealth’s responsibilities as related to continuous monitoring, evaluation, and improvement in access and quality of services provided under the Medicaid Behavioral Health (BH) HealthChoices (HC) Managed Care Program as promulgated by the Balanced Budget Act of 1997, section 1932 and other related Federal and State laws and regulations. This is a professional management-level position that synthesizes findings from different data and record sources, interviews, and interactions with consumers and other internal and external stakeholders to determine compliance, identify risks or potential liabilities with relevant BH HC Standards for Managed Care Organizations (MCO) and individual BH HC Primary Contractors. This position provides technical assistance, manages projects, and collaborates with a wide variety of partners to support the development and implementation of quality initiatives, including performance improvement activities, evidence-based behavioral healthcare quality practices and programming, and other priority areas as identified by OMHSAS. The work of this position is completed with a high degree of independence under the supervision of the Quality Assurance/Risk Management Director of the OMHSAS Division of Quality Management within the Bureau of Quality Management and Data Review. Additionally, this position collaborates and communicates with individuals and teams within the Division, Bureau, other OMHSAS Bureaus, and other DHS Program Offices. |
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Description of Duties: Describe in detail the duties and responsibilities assigned to this position. Descriptions should include the major end result of the task. Example: Types correspondence, reports, and other various documents from handwritten drafts for review and signature of the supervisor. The incumbent: • Conducts quality assurance and risk management reviews of BH HC Primary Contractors and BH-MCOs for regulatory compliance to state and federal regulations, standards and performance of operations relative to the HealthChoices Program.• Completes Annual & Triennial desk reviews of the Program Evaluation Performance Summary (PEPS) Reviews for assigned BH HC Primary Contractors and BH-MCOs. This includes evaluating Program Descriptions, Quality Management (QM) Work Plans, Annual Evaluations, Provider Profiles and policies for compliance to Federal and State standards, including adherence to requirements, meeting performance benchmarks and advancing initiatives targeting the implementation and sustainability of clinically sound practices and evidence-based practices for providers and direct services for consumers. Conducts quality assurance compliance reviews using relevant federal and state standards for documentation in MH and SUD-related service Prior authorization requests, service Denials, First and Second Level Complaints, Grievances, and Fair Hearing practices of BH-MCO and BH HC Primary Contractors. Monitor and maintain an overview of the External Complaints and External Grievance process, conducted by the External organization. • Monitors and evaluates BH-MCO Service Denial Letters for clarity and adherence to medical necessity language. • Conduct BH-MCO Onsite Reviews and audits, which includes, leading, interviewing and reviewing documentation that targets identified service areas for medical necessity, appropriateness, access, quality, risk, as well as, efficient and effective delivery of care. This includes participating in case reviews and consultative sessions with the management team, clinical staff, and multidisciplinary teams of the BH-MCO and Primary Contractors. • Collaborates with other DHS Program Offices,on quality assurance, risk management reviews, as well as, complaint and grievance filings relating to mental health and substance abuse services and clinical best practices. • Lead OMHSAS PEPS review process, by facilitating activities of the Bureau of Community & Hospital Operations; the Bureau of Policy, Planning and Program Development; and the Bureau of Children’s Behavioral Health Services. Serve as the Subject Matter Expert for programmatic and policy issues relevant to performance measurements, quality improvement, and monitoring/compliance changes, as outlined by federal and state policy for BH HC Managed Care Program. Stay abreast of federal and state level changes as a result of policy and regulatory changes made by Centers for Medicare and Medicaid Services (CMS). • Serves as an OMHSAS staff resource for analyzing and interpreting new and existing regulations, policies, procedures, standards, and clinical guidelines relative to quality in behavioral health services. This activity can include consulting and collaborating with community-based programs, the OMHSAS Executive Leadership, Bureau of Community Operations, Bureau of Children’s Behavioral Health Services, Bureau of Policy and Program Development and the Office of Medical Assistance Programs in developing and interpreting QM policy and practices. • Reviews, interprets and analyzes proposed legislation that has reference or impact on Behavioral Health services and provides written input to the OMHSAS response generated by the Bureau of Policy and Program Development. • Participates in developing and implementing systems for reviewing and monitoring data and quality benchmarks, plans, policies, procedures and timelines for quality assurance/risk management activities to be implemented by Primary Contractors and BH-MCO • Effectively identifies and addresses deficiencies, as identified, in compliance. Develop, issue and manage the Corrective Action Plans (CAPs), in order to drive increased access, quality improvement, efficiency of service provision, and the implementation of clinically sound and evidence-based practices. • Develop and direct the OMHSAS’ Quality Assurance and Performance Improvement (QAPI) programs, Statewide Performance Improvement Program (PIP), and other Quality Improvement Projects (QIPs)in collaboration with the State’s External Quality Review Organization (EQRO). Keep Executive Leadership and other Bureaus informed of status updates, changes and modifications. • Review and edit for accuracy, to eliminate errors and omissions, to make sure OMHASA and are highlighted by the State’s EQRO to summarize to CMS compliance…. within the ATR submitted by our EQRO in compliance • Monitors HC Contractor meetings related to Quality for PEPS compliance and evidence of improvement in member and system outcomes and service processes. This includes monthly and quarterly Quality Management Committees, Quality Improvement, Utilization Management, Utilization Review and Field Office Monitoring Meetings, as assigned. • Reviews BH HC data submissions, develops and provides regular and special request reports both orally and in writing, including data displays and use of Microsoft Excel, PowerPoint, Word and Outlook. This includes data and reports for Consumer/Family Satisfaction, Performance Improvement Projects, Quarterly Monitoring Results, special studies and research projects. • Prepares written and statistical reports, and compiles data analyzing the trends and outcomes regarding OMHSAS program and service initiatives that are reported to the Executive level of OMHSAS, other OMHSAS and Department personnel, consumers, counties, primary contractors and BH-MCOs. This includes data and reports for the PeopleStat Initiative, the Integrated Care Plan (ICP) and the Integrated Community Wellness Centers (ICWCs), Value Based Purchasing (VPB), Community Based Care Management Program (CBCM), Maternal Mental Health Affinity Group (MHAG), 988 initiatives, Fair Hearing, and other initiatives related to new regulatory requirements. • Participates in external quality review meetings and activities in order to ensure compliance with Federal and State regulations related to the HealthChoices program. • Participates in developing benchmarks for community-based services and managed care compliance to meet the Department’s goals for continued improvement in the quality and utilization of mental health and substance abuse service delivery. • Participates in HealthChoices contract readiness reviews by reviewing and evaluating contractor readiness and ongoing performance in the areas of quality management, risk management, and service utilization. • Designs surveys, conducts research studies, and participates in developing the methodology to acquire and disseminate data. Synthesizes data and develops reports for leadership. • Serves as a member of workgroups related to the initiatives and special projects of the Department of Human Services, and the Office of Mental Health and Substance Abuse Services. • Shares responsibility in answering the Consumer Information Line (CIL) and responding to consumer complaints and referrals. • Consults with and provides technical assistance and guidance to professional, technical, and clerical/administrative support staff. • Performs other job-related duties as required. |
Decision Making: Describe the types of decisions made by the incumbent of this position and the types of decisions referred to others. Identify the problems or issues that can be resolved at the level of this position, versus those that must be referred to the supervisor. Example: In response to a customer inquiry, this work involves researching the status of an activity and preparing a formal response for the supervisor’s signature. This work involves considerable independence, initiative and judgment while operating within established Commonwealth policy, procedures and guidelines. Supervisory guidance and review is required for complex, sensitive or changing priorities as needed; or when a procedure or policy could adversely have effect on the health and welfare an individual or individuals receiving mental health and/or substance abuse services, or be inefficient or costly to the system. Work is reviewed for conformance with established criteria, standards and procedures set forth by the division, bureau, department, state and federal regulations and policies. Performance of the incumbent is evaluated through conferences and meetings, observation of the efficiency, economy and effectiveness of practices employed and results achieved, and the overall performance (project completeness and performance standards) in meeting stated work plans, goals and objectives. Supervision and direction is provided through individual and team meetings |
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Requirements Profile: Identify any specific experience or requirements, such as a licensure, registration, or certification, which may be necessary to perform the functions of the position. Position-specific requirements should be consistent with a Special Requirement or other criteria identified in the classification specification covering this position. Example: Experience using Java; Professional Engineer License Experience: Licenses, registrations, or certifications: 1. N/A 2. N/A 3. N/A 4. 5. 6. |
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Essential Functions: Provide a list of essential functions for this position. Example: Transports boxes weighing up to 60 pounds.
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