Quaity Assurance Clinician

This position is responsible for assessing and improving both the quality of care and quality of documentation provided by the clinical staff of FCS by using a comprehensive case record review and quality assurance process including monitoring activities, training and reporting. Identifies CCBHC training needs and provides individual and group consultation classes or technical assistance to improve documentation, quality of care and utilization of EBTs. Coordinates specialized training needs with program supervisors to enhance documentation skills. Specific focus on quality measures and CCBHC components

POSITION SPECIFIC DUTIES & RESPONSIBILITIES:    

Case Record Review

• Conduct quarterly case record reviews of randomly selected open and recently closed cases for each assigned program for quality improvement, documentation of CCBHC fidelity and risk management purposes.
• Conduct case record reviews to evaluate the quality of clinical services provided and the presence, clarity, quality, continuity and completeness of required document
• Assess records for appropriate screenings, assessment, diagnosis, level of care, comprehensive care plans, attainable and measurable goals, length of treatment, discharge planning and overall quality of care.
• Assess records for provision of CCBHC required services
• Review and Monitor:

•  Compliance with external clinical documentation standards; agency policies and procedures for clinical documentation
• Clinical services are appropriate for client needs and services are justified by quality clinical documentation
• Required COA and ODMHSAS assessments, progress notes, service/ comprehensive care plans, and other clinical documentation
• Documentation of quarterly case supervisory review
• Comprehensive Care Plans address identified assessment needs
• The client participated in the comprehensive care plan development
• Comprehensive Care Plans reviewed by specified date
• Case notes reflect agreed upon goals and objectives
• Services were culturally sensitive
• Treatment meets medical necessity standards and utilization review standards
• Follow up for referrals and needed services are documented
• Fidelity to specific treatment intervention model

Quality Measures Review

• Assess records for services to address client health measures
• Assess records for evidence-based treatment utilization consistent with diagnosis of the client
• Consult with Director of Quality Assurance, PQI and Risk regarding EHR functions in relation to CCBHC services and quality measures

Training, Consultation, Technical Assistance

• Assist supervisors with training newly hired staff and any identified staff not complying with documentation standards by:

• Reviewing progress notes and comprehensive care plans
• Identifying areas of improvement and providing educational training on how to meet competency for documentation

• Identify patterns of non-compliance with accrediting standards and create process to assist individual staff and programs with compliance. Multiple means may be utilized such as:

• Reviewing or creating reports to assist in identifying all required forms in chart, time frames, etc.
• Micro trainings to assist with documentation of progress notes and comprehensive care plans, authorizations to disclose information, filling out assessments and other items that may not be met
• Training supervisors and onboarding ambassadors in most current certification standards.

• Use case record review results to identify quality enhancement areas and clinical documentation improvement training needs and work in cooperation with the Director of Clinical Training and Director of Quality to develop training materials, courses, and tips to address identified needs
• Provide technical assistance to correct deficiencies and monitor providers' progress toward meeting goals
• Provide training and consultation to clinical, supervisory, and management staff about enhancing quality documentation, utilization standards and areas for quality improvement

• Provide timely information about improving quality clinical practices, documentation trends and risk; staff training needs; needed performance and quality improvement actions and other clinical documentation issues
• Arrange meetings with supervisors as needed to communicate case record review processes and to provide program specific training related to case record reviews, quality clinical practices and quality clinical documentation.

Monitoring and Investigation

• Establish focused monitoring activities to detect adverse outcomes and other care related issues
• Refers cases for appropriate supervisory review when established criteria are not met.
• Reports all monitoring activities to the Director of Quality Assurance, PQI and Risk

Report Findings and Recommendations

• Identify potential quality issues and report quarterly or as needed to appropriate supervisor for a plan of correction.
• Identify barriers and opportunities for improving services
• Work closely with the Director of Quality to develop routine reports, trend analysis, findings and recommendations for quality improvement activities to inform clinical practices and documentation enhancement and to reduce or mitigate risk.
• Prepare quarterly data, trend analysis report and case record review findings and quality improvement recommendations to appropriate parties: Director of Quality, Training Director, PQI committees, Clinical Supervisors.

External Audits

• Identify charts to utilize for external audits by:

• Coordinating with program supervisors for the ongoing monitoring of charts to ensure compliance with all required standards.
• Assist in creating any forms or reports to identify charts for external certifications
• Create and implement levels of review to prepare charts for certification. Ex: Level one review would indicate all forms necessary are in chart, level two would indicate treatment needs met, etc

• Coordinate case record review activities for external audits, certifications and accreditation of programs to ensure agency compliance.

• Prepare the case record review schedule for external audits, certifications, and accredidation site visits

• Provide consultation to clinical supervisors on preparing for case record reviews by external entities.

Administrative

• Remain current with changes in agency programming, evidence-based practices, quality case record reviews and clinical documentation best practices
• Maintain “MITT” knowledge of myAvatar software to understand comprehensive care plan design/modification/review requirements and to stay abreast of myAvatar updates that affect clinical documentation.
• Consistently meet or exceed case record review productivity expectations.
• Maintain and update quality case record review operational procedures and quality case record review data collection tools.
• Maintain case record review spreadsheets in a timely manner to document staff and program compliance with case record review criteria and areas where corrective actions are needed.
• Obtain and maintain working knowledge of clinical record documentation requirements for COA and ODMHSAS standards, Oklahoma Health Care Authority policies, including CCBHC and other funders’ requirements. Provide timely information updates to the Director of Quality, the Director of Clinical Training and clinical supervisors.
• Develop working knowledge of clinical documentation requirements for treatment intervention models and evidence-based practices utilized by specific programs and uses this knowledge to inform case record review feedback to programs and recommendations for quality improvements.
• Ensures confidentiality of peer review records and process 

QUALIFICATIONS

education:

• Master's Degree in Social Work or related discipline.

EXPERIENCE:

• 3+ years' experience providing master's level mental health services.

PERFORMANCE COMPETENCIES: 

• Essential Behaviors
• Case Record Reviews
• Identify Quality Enhancement Areas
• Training, Consultation, and Risk Management
• Facilitate Learning Lab Components
• Clinical Record Documentation Requirements

KNOWLEDGE/SKILLS/ABILITIES:

• Knowledge of Council on Accreditation (COA) and Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) clinical record documentation standards
• Knowledge of the elements of quality clinical practice and documentation
• Knowledge of the scope of practice for all F&CS direct service worker roles.
• Profecient in Microsoft Office
• Excellent Oral and Written Communication Skills.
• Ability to identify and communicate both verbally and in writing clinical documentation strengths and improvement opportunities.
• Ability to Work Independently
• Ability to Multitask

CERTIFICATIONS/LICENSES:

• Must be licensed as an LCSW, LPC, LMFT, LADC or other mental health professional
• Must possess a valid Driver License and satisfactory driving record to use agency and/or personal automobile to travel to locations other than primary office.

OTHER INFORMATION

SAFETY SENSITIVE JOB CLASSIFICATION:

This job is classified as a “safety-sensitive” position as defined by the Oklahoma Medical Marijuana and Patient Protection Act.  Due to the “safety-sensitive” classification, an employee in this position would be subject to drug and alcohol testing, including random testing.  Marijuana is one of the substances included in the drug panel screening.  Possession of a medical marijuana license will not excuse you from the testing process or the consequences of testing positive for marijuana per the Family & Children’s Services Drug Free Workplace Policy, including possible revocation of a job offer or dismissal from employment.