Under leadership of the Director of Incidents, Grievances, and Appeals, the Supervisor of Clinical Incidents, Grievances, and Appeals will supervise and manage the incident reporting function and provide clinical guidance member appeals and grievance functions.
This position is full-time remote opportunity. The selected candidate must reside in North Carolina.
Responsibilities & Duties
Supervision of Incident Reporting Team
Provide daily administrative and clinical supervision to incident reporting staff
Ensure that timelines for processing and escalating incident reports are in compliance with state requirements
Provide training and technical support to providers related to incident reporting compliance
Work closely with legal and compliance departments to ensure that incident reporting policies are compliant with all relevant regulations and contractual requirements
Participate in state calls related to incident reporting to remain current with NC-IRIS: the state incident reporting electronic system
Provide data related to level III incidents and incidents posing potential risk to plan leadership in a timely manner and ensure timely responses to incidents
Compile and analyze data related to incident reporting trends and patterns to share with internal and external audiences
Clinical Quality Review Committee (CQR)
Maintain and update the workflow and desk procedures for the CQR committee
Collaborate with the grievance and incident teams to determine cases to be presented to the committee
Serve as chair of the CQR Committee. Collaborate with the Medical Team to review cases and make follow up recommendations as needed
Lead incident reporting staff in collaborating with providers to complete follow up recommendations
Clinical Consultation and Support
Develop and implement a process for referring grievance and appeals cases for clinical consultation
Participate in clinical staffing of grievances and appeals as necessary
Coordinate responses to concerns submitted to the plan via SNOW tickets
Represent the Incident, Grievance and Appeals teams on various internal committees including those addressing high clinical risks to members’ health and safety
Manage and Develop Staff
Work with Human Resources and the director of Incidents, Grievances, and Appeals to attract, maintain, and retain a highly qualified and well-trained workforce
Ensure staff are well trained in and comply with all organization and department policies, procedures, and business processes
Organize workflows and ensure staff understand their roles and responsibilities
Ensure the department has the needed tools and resources to achieve organizational goals and to support employees and ensure compliance with licensure, regulatory, and accreditation requirements
Actively establish and promote a positive, diverse, and inclusive working environment that builds trust
Ensure all staff are treated with respect and dignity
Ensure standards are transparent and applied consistently, impartially, and ethically over time and across all staff members
Work to resolve conflicts and disputes, ensuring that all participants are given a voice
Set goals for performance and deadlines in line with organization goals and vision
Effectively communicate feedback and provide ongoing coaching and mentoring to staff and support a learning environment to advance team skills and professional development
Cultivate and encourage efforts to expand cross-team collaboration and partnership
Minimum Requirements
Education & Experience
Required:
Master’s degree in health and human Services field from an accredited college/university with five (5) years in Behavioral Health service provision and/or management with two (2) years’ experience in Incident Reporting or Quality Management
Provisional or full licensure as LCSW, LCMHC, LPA, or LMFT required.
Preferred:
Prior experience with incident reporting via NC-IRIS and supervisory experience
Knowledge, Skills, & Abilities
Self-motivated, able to take initiative, and work independently with minimal oversight to meet timelines, strong follow-through skills and a solutions-oriented attitude.
Ability to analyze essential facts, make timely and sound decisions, make recommendations, and resolve performance and job-related issues.
Excellent written and verbal communication skills
Advanced knowledge in the use of web-based technology and Microsoft Office applications such as Word, Excel, and Power Point. Proficient with database entry
Working knowledge of medical insurance and managed care principles and knowledgeable of CPT and ICD-10 coding systems
Knowledge of NCQA requirements of utilization review, appeal rights and responsibilities, and regulatory requirements at the state and federal level for health care administration and Carrier standards
Salary Range
$75,600 - $100,107/Annually
Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.
An excellent fringe benefit package accompanies the salary, which includes:
Medical, Dental, Vision, Life, Long Term Disability
Generous retirement savings plan
Flexible work schedules including hybrid/remote options
Paid time off including vacation, sick leave, holiday, management leave
