CLINICAL SPECIALIST - PERFORMANCE MONITOR

Under the general supervision of the Director of Quality Improvement, the Performance Improvement and Performance Monitor staff is responsible for conducting on-site provider reviews and ensuring compliance of assigned providers to federal, state, local, contractual, regulatory, and best practice standards and guidelines.  

*PRINCIPAL DUTIES AND RESPONSIBILITIES: *

Oversees and monitors the development and implementation of the quality improvement program.

Develops and implements the quality improvement plan in accordance with the QAPIP of the organization, federal and state laws/regulations and accreditation standards.

Performs analytical monitoring of contractors and providers.

Monitors Medicaid and contractual agreements.

Monitors Medicaid Verification Claims and Michigan Mission Based Performance Indicators (MMBPI) data.

Develops performance improvement targets for quality, service and the efficiency of the organization.

Implements changes targeted at system improvement.

Measures and evaluates attainment of results.

Provides consulting, technical and clinical assistance.

Implements systematic improvements.

Measures cost savings.

Ensures assigned service providers maintain quality services.

Assures improvement activities are documented and reported.

Analyzes, updates, and modifies standard operating procedures and processes to continually improve QI services.

Plans, organizes, manages and leads work processes of the quality improvement program (QI).

Designs key elements of the strategic operating plan.

Conducts system design.

Conducts system reengineering.

Performs project management and quality improvement functions.

Performs statistical analysis and data analysis.

Ensures continuous quality improvement.

Performs utilization management.

Assists in organizational studies and evaluations.

Designs systems and procedures.

Conducts work simplification and measurement studies.

Prepares operations and procedures manuals.

Monitors compliance with Residential providers within the DWIHN provider network.

Works with providers to improve the quality of care and services.

Assists with the NCQA accreditation process.

Sets standards, conducts performance assessments and conducts remote and on-site monitoring of providers in the network.

Monitors the facility quality improvement process and provides facility provider education and oversight. 

Conducts all MDHHS and Integrated Care Organization (ICO) site visits.

Develops and implements corrective action plans and improvement plans. 

Oversees new program enrollment and Medicaid Enrollment reviews which involves site visits to ensure that new programs or programs requiring Medicaid enrollment meet the minimum requirements for participation in the DWIHN network.

Ensures that Home and Community Based Services (HCBS) are based on the person-centered planning processes and provided in settings where individuals have full access and integration into the community.

Ensures the settings in which HCBS services are provided afford individuals independence and autonomy.

Ensures that any setting providing HCBS services comply with MDHHS rules in order to continue to receive Medicaid funding to pay for HCBS services.

Ensures that DWIHN's residential and non-residential settings meet all regulatory requirements and provide a safe and healthy environment, that staff are qualified and that the needs identified in the individual plan of services (IPOS) are being met.

Provides Annual Residential reviews that includes reviewing clini