QA QI Analyst- DMC-ODS
6 days ago
Sacramento
Job DescriptionDescription: Description The CalMHSA Way: • Curiosity, • Innovation, • Grounded in Mission, • Ownership, • Clarity SUMMARY: The Quality Management Analyst supports CalMHSA’s regional Drug Medi-Cal Organized Delivery System (DMC-ODS) administrative model by coordinating quality management, utilization management, provider monitoring, reporting, documentation, and compliance workflows. This position works closely with County Behavioral Health Plans, providers, CalMHSA staff, and state partners to support the implementation of DMC-ODS requirements across access, network, utilization management, reporting, member information, and quality improvement functions. The Quality Management Analyst plays a key role in maintaining audit-ready documentation, tracking provider and system performance, coordinating credentialing and recredentialing materials, supporting site and chart reviews, monitoring grievances and quality trends, and developing workflows and tools to support consistent implementation of DMC-ODS requirements. This role requires strong organizational skills, as well as familiarity with Medi-Cal behavioral health managed care, county behavioral health plan operations, and DMC-ODS program requirements. DUTIES AND RESPONSIBILITIES include but are not limited to: • Maintain utilization management tracking tools, logs, and documentation files, including authorization requests, reauthorization timelines, documentation status, and follow-up items., • Coordinate credentialing/recredentialing packets and provider directory updates., • Track provider onboarding, readiness, required documentation, training completion, and operational implementation activities., • Coordinate provider site reviews, chart reviews, documentation reviews, and monitoring activities, including scheduling, materials preparation, file organization, and follow-up tracking., • Track provider findings, corrective action plans, remediation activities, due dates, and evidence of completion., • Collect, organize, and analyze quality, utilization, access, grievance, provider performance, and compliance data to identify trends, risks, and follow-up needs., • Track grievances, appeals, NOABDs, provider complaints, and related performance data to support reporting, trend analysis, and quality improvement activities., • Coordinate and track required DMC-ODS reporting workflows, including CalOMS, DATAR, TADT, 274/network adequacy, ASAM level-of-care reporting, and other state reporting requirements, as assigned., • Develop and maintain program workflows, desk guides, tracking tools, templates, training materials, and audit-ready documentation for DMC-ODS quality management and provider operations., • Monitor DHCS guidance, contract requirements, and operational changes, and help translate requirements into tracking tools, workflow updates, and implementation materials., • Support preparation for DHCS reviews, EQRO activities, audits, readiness reviews, provider monitoring, and other compliance or oversight activities., • Coordinate meetings, agendas, materials, notes, follow-up items, and documentation for quality management, provider monitoring, county coordination, and internal implementation workgroups., • Provide operational follow-up and technical assistance to providers and counties regarding documentation requirements, reporting workflows, provider monitoring, directory updates, and quality management processes., • This position will have access to various applications that house confidential information related to consumer demographics and behavioral health; ensure that access is used responsibly, maintaining the integrity and security of systems while preventing accidental or malicious misuse., • Perform other duties as assigned, demonstrating flexibility and commitment to organizational success. BACKGROUND CHECK ELIGIBLE DUTIES This position will have access to various applications that house confidential information, including county behavioral health records, Protected Health Information (PHI), substance use disorder treatment records, consumer demographic data, clinical documentation, provider credentialing files, utilization management documentation, grievance and appeal records, quality management materials, and compliance-related documentation. The incumbent must handle all confidential information in accordance with HIPAA Privacy and Security Rules, 42 CFR Part 2 regulations, applicable state confidentiality requirements, and CalMHSA security policies, ensuring that access is used responsibly while maintaining the integrity and security of systems and preventing accidental or malicious misuse. Qualifications An acceptable equivalent combination of education, experience, and skill may be considered. EDUCATION/EXPERIENCE: • Bachelor’s degree in Public Health, Behavioral Health, Social Work, Healthcare Administration, Public Administration, Psychology, Sociology, or related field, required., • Minimum of three (3) years of experience in behavioral health, substance use disorder services, quality management, utilization management, compliance, provider monitoring, program administration, data/reporting, or a closely related field, required., • Experience with DMC-ODS, Medi-Cal behavioral health managed care, substance use disorder treatment systems, or county behavioral health plan operations, strongly preferred., • Experience working within or directly with a County Behavioral Health Plan, particularly supporting DMC-ODS quality management, reporting, utilization management, provider monitoring, or compliance functions, strongly preferred., • Experience coordinating audits, site reviews, chart reviews, credentialing/recredentialing files, provider monitoring, corrective action plans, or quality improvement activities, preferred., • Experience developing workflows, tracking tools, policies, procedures, training materials, or program implementation resources, preferred. SKILLS AND ATTRIBUTES: • Strong understanding of DMC-ODS, Medi-Cal behavioral health managed care, county behavioral health systems, and provider compliance requirements., • Knowledge of quality management, utilization management, provider monitoring, grievances/appeals, network adequacy, timely access, and state reporting workflows., • Strong organizational skills and ability to maintain detailed, accurate, and audit-ready records., • Strong analytical skills, including the ability to review data, identify trends, track issues, and summarize findings clearly., • Excellent written and verbal communication skills, including the ability to prepare reports, summaries, procedures, workflows, and training materials., • Ability to coordinate complex processes involving multiple stakeholders, deadlines, documentation requirements, and follow-up items., • Ability to interpret regulatory, contractual, and operational requirements and translate them into practical workflows and tracking tools., • Strong attention to detail and ability to identify inconsistencies, missing information, and compliance risks., • Ability to work effectively with counties, providers, state partners, internal teams, and external stakeholders., • Ability to manage multiple priorities, adapt to changing requirements, and maintain follow-through in a fast-paced implementation environment., • Demonstrated professionalism, discretion, and ability to maintain confidentiality when handling sensitive behavioral health, provider, and compliance information. COMPUTER SKILLS: Demonstrate the ability to use a computer and applicable computer software effectively. Intermediate knowledge of Excel & Word, PowerPoint, Adobe, and Outlook required. Experience with electronic health records, utilization management platforms, provider management systems, project management tools, or data dashboards preferred. LANGUAGE SKILLS AND MATHEMATICAL SKILLS: Demonstrate the ability to read, comprehend, and respond appropriately through written or verbal form; demonstrate tactfulness when communicating with internal staff, counties, providers, state partners, and other stakeholders. Ability to communicate effectively with a variety of audiences. Ability to add, subtract, multiply, and divide in all measure units, using whole numbers, common fractions, and decimals. REASONING: Demonstrate the ability to effectively apply common sense, regulatory requirements, and operational judgment to daily tasks; demonstrate the ability to work independently with limited supervision; demonstrate excellent analytical and critical thinking skills; demonstrate the ability to conduct research, ask appropriate probing questions, identify risks, and develop practical solutions. PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is frequently required to sit and stand; use phone and headset; use hands, arms, finders to type; answer phones; write; use calculator; demonstrate strength to lift and carry materials weighing up to 10 pounds; demonstrate clear vision to read printed materials and a computer screen; hearing and speech to communicate in person and over the telephone. SENSORY DEMANDS: The incumbent must spend long hours in intense concentration. The incumbent must also spend long hours on the computer entering information which requires attention to detail and high levels of accuracy. MENTAL DEMANDS: There are a number of deadlines associated with this position, which may cause significant pressure. The incumbent must also attend to a wide variety of individuals regarding various topics/challenges. REGULAR WORK SCHEDULE: Schedule varies depending on business needs; however, regular company business hours are 8:00am to 5:00pm, Monday – Friday. Requirements:
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