|Title:||Clinical Compliance Director|
|Location:||3875 Tiger Bay Road, Daytona Beach, FL 32124|
Working Hours: 40 hrs/week; Mon-Fri; 9a-5p
A currently competent Clinical Compliance Director who provides professional review of clinical services and staff’s clinical activities via the client record to assure that client placement and service delivery complies with the Utilization Management standards of Stewart-Marchman-Act Behavioral Healthcare (SMA). The Clinical Compliance Director acts as a liaison between third party payers or the payer’s managed care organization and SMA staff serving their covered clients. The Clinical Compliance Director will as in an advisory capacity to the clinical staff of SMA’s treatment components. The Clinical Compliance Director will train clinical staff and managers in the principles of UM and the criteria of SMA’s UM Plan. The Clinical Compliance Director will assist in the development of SMA’s UM Plan. The Clinical Compliance Director will review client records for issues related to compliance with SMA service standards and quality improvement as assigned by the department supervisor. Client record reviews will concern treatment services and issues of adult and/or adolescent clients who are experiencing mental health and/or substance abuse disorders/problems and may have criminal/delinquency behavior problems. The Clinical Compliance Director will utilize professional knowledge of behavior health treatment programming and patient placement criteria to interface with all disciplines of the treatment teams of the respective programs to which they are assigned review responsibilities. The Clinical Compliance Director will have total responsibility for the functions of the UM Department.
Graduation from an accredited school with a minimum of a Master’s degree in the human services field. Within the last five years must have had two years of experience in behavioral health treatment services, especially as it relates to the documentation of those services in the client record. One year of experience in a setting where it was necessary to communicate orally and in writing to inform, advise, or train others about client issues, treatment service delivery, documentation in client records or UM principles. Board certification as a Quality Assurance/Utilization Review Professional by the American Board of Quality Assurance and Utilization Review Physicians or equivalent agency preferred. A Certified Addictions Professional (CAP) is preferred. Experience with American Society of Addictions Medicine Patient Placement Criteria is preferred. Experience with CARF, Medicaid, and Managed Care requirements is preferred.
- Must be knowledgeable and demonstrate competency in current best practices of behavioral health treatment and related services, especially as it relates to documenting the course of treatment and patient placement criteria in the client record.
- Depending on assignment must have knowledge of typical diagnoses, treatment services, and developmental issues for adolescents in general, delinquent adolescents, adults and pregnant/post partum women who are admitted to a mental health and/or substance abuse treatment setting.
- Demonstrates proficiency with assigned client populations in performing utilization reviews in records of clients with specific problems and needs.
- Knowledge of growth and development.
- Ability to assess age specific data.
- Ability to interpret age specific response to treatment.
- Knowledge of the treatment needs of adolescent mental health, substance abuse, co-occurring, ADD, ADHD, conduct, and oppositional defiant disorders.
- Knowledge of the treatment needs of adult mental health, substance abuse, and co-occurring diagnoses of affective disorders, anxiety disorders, PTSD, and antisocial personality disorder.
- Knowledge of the treatment needs of adult pregnant/post -partum women with mental health, substance abuse, and co-occurring diagnoses of affective disorders, anxiety disorders, PTSD, and antisocial personality disorder.
- Proficiency in working with telephone system and telephone etiquette.
- Proficiency in working with computer hardware and software, when assigned.
- Coordinates and supervises daily activities of the UM Department.
- Performs concurrent reviews of client records in accordance with operating procedures of SMA UM Plan to certify appropriateness of admission and continued stay and discharge planning based on the criteria of the UM Plan.
- Performs retrospective reviews of client records according to the operating procedures of the UM Plan to certify discharge appropriateness of discharge/referrals based on the criteria of the UM Plan.
- Writes and distributes to staff legible, informative, and understandable notices of non-compliance issues identified through reviews of client records with copies to their supervisors.
- Acts as an advisor to the staff and program supervisors through in-service trainings, individual meetings and written communications issues pertaining to the documentation expectations of insurance companies and other third party payers.
- Submits a monthly written and oral report to the Performance Improvement Council detailing the number and percentages of authorizations for each level of care. Reports on a monthly basis the type of documentation problems that are causing denial of payment for services provided.
- Submits a written annual summary report of monthly reports for each calendar year and presents orally to PIC upon request.
- Assists in the development of operating procedures and admission, continued stay, and discharge criteria for SMA's UM Plan with members of the PIC and/or the Performance Improvement department.
- Improves professional knowledge and sill base relevant to utilization management by attending seminars, trainings, and conferences and by reading current literature.
- Participates in required SMA in-service trainings to maintain employment.
- As assigned, assists in the maintenance of SMA's compliance with treatment and documentation requirements of funding sources, performance improvement, and accreditation activities.
- Acts as liaison between SMA staff and insurance companies, funding sources, or their managed care organizations when client’s health care is being managed under a managed care plan.
action employer, and a tobacco and drug-free workplace.