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LOCATION: Remote - this is a home based, virtual position. Candidate must reside in North Carolina or within 40 miles of the NC border.

GENERAL STATEMENT OF JOB

Under the supervision of the GRIT Manager, the Grievance Resolution Specialist (GRS) will resolve grievances/complaints and process incident reports. The GCIRS is responsible for resolving grievances and complaints received by Vaya Health by or on behalf of any member/recipient who is dissatisfied with a Vaya contracted provider, a Vaya employee, or any aspect of Vaya or its service delivery system. This is accomplished by processing complaint and grievance reports, coordinating resources, and communicating with all relevant parties throughout the resolution process in a manner that is timely, thorough, fair, impartial, consistent, and compliant with applicable laws, rules and regulations. The GRS is responsible for ensuring all regulatory and accrediting guidelines/requirements are upheld throughout the resolution process. The individual must be knowledgeable about Vaya's internal processes as well as providers, services, and stakeholders throughout the public behavioral health and intellectual/ developmental disabilities (IDD) system. The GRS is responsible for reviewing incidents submitted into the Incident Response Improvement System (IRIS), Back-up staffing reports, and QM-11 reports. The GRS provides support and administrative functions to the Critical Incident Review Committee (CIRC), including document preparation, records requests and meeting facilitation.

ESSENTIAL JOB FUNCTIONS

Member/Recipient Grievance/Complaint Resolution:

The person in this position is responsible for managing assigned complaints and grievances by ensuring the concern of the individual is properly acknowledged, documented, and addressed to work toward informal resolution by:

• Answering questions from members, recipients, stakeholders, or others about the complaint/ grievance process
• Timely resolving complaints and grievances through the following activities:
  1. Phone interviews with the filer and person(s) who have a legitimate role in the issue to be resolved (i.e. staff, legal guardians, providers, care managers, etc.) to obtain additional information or clarification
  2. Consultation with Vaya staff, licensed clinicians, and subject matter experts
  3. Provider record/ information request and record review
• Maintain timely responses to inquiries regarding grievances and complaints
• Provide recommendations and direction to both service providers and members in an attempt to eliminate repeated grievances of a similar nature
• Provide feedback to providers regarding written responses to grievances and complaints
• Recognize grievances and complaints that include health and safety issues that need to be immediately addressed by accurately depicting the situation in a case staffing to the CMO

Incident Report Review and Tracking:

This position reviews incident reports from all Vaya provider agencies within the catchment area and incident reports from provider agencies that have Vaya enrollees who live outside the catchment area. IRIS is a mandated electronic system for provider and LME/MCO to document the occurrence of Level II and III incidents. Incident review and response includes the following:

• Ensure the incident report is complete and has accurate information, request any additional or missing information
• Evaluate the cause/prevention section and provide technical assistance to the provider when standards for future prevention are not met
• Evaluate the likeliness that the incident will be in the media and alert the CMO
• Tracking and trending of incidents; report any trends of concern to CIRC
• Track and trend back-up staffing reports and compile and prepare data for quarterly reporting as needed
• Track and trend QM-11 (level 1 incident) reports

KNOWLEDGE, SKILL & ABILITIES:

• Excellent to develop practical, thorough, and creative solutions to complex problems
• Excellent to conduct data analysis and recognize trends is essential
• Excellent to effectively communicate trends within Vaya to address potentially serious issues is required
• Excellent to actively listen to grievances and complaints while maintaining a positive outlook and attitude with members, co-workers, and stakeholders
• Ability to work remotely (from home) with little supervision and function as a self-starter
• Flexible worker who readily accepts assigned tasks, manages unfamiliar situations, and searches for every opportunity to help the team
• Excellent time management skills, including the ability to manage competing priorities and to complete tasks in a timely and accurate manner
• Highly productive and motivated individual who takes pride in a job well done, demonstrates initiative and is committed to self-accountability
• Strong attention to detail and extreme precision and accuracy
• Ability to work collaboratively with individuals at all levels and with varying backgrounds both within and outside of Vaya and build strong working relationships
• Strong organizational skills with the ability to multi-task
• Ability to manage constant transformation and adapt to changing mandates from regulatory authorities as well as Vaya executive leadership
• Ability to maintain the confidentiality of sensitive information in accordance with applicable laws, policies, rules and regulations
• Ability to problem-solve and provide practical, thorough, and creative solutions to work tasks
• Ability to learn, interpret independently, and apply a variety of complex policies and procedures
• Good working knowledge and proficiency in Adobe and Microsoft Office 365 products (Word, Excel, Outlook, PowerPoint, Teams, Visio, SharePoint, etc.)
• Familiarity with Navex software products (PolicyTech, EthicsPoint) a plus
• Thorough knowledge of how to use standard office equipment, including printers, scanners, and fax machines
• Knowledge of North Carolina's public behavioral health and I/DD system, including Vaya providers, services, and stakeholders, preferred
• Ability to work independently is essential -Ability to research multiple Electronic Records Systems
• Ability to understand claims data
• Ability to understand both physical and behavioral health diagnoses
• Ability to synthesize information gathered in the grievance process to write a succinct resolution letter
• Ability to interact with team while performing grievance resolution lead duties in a respectful manner
• Ability to use critical thinking skills, work independently with little or no direction, demonstrate initiative, and function as a self-starter
• Ability to develop practical, thorough, and creative solutions to complex problems

QUALIFICATIONS & EDUCATION REQUIREMENTS

High School diploma or GED required. Bachelor's degree in a Human Services field preferred. A minimum of three years of experience in quality management, data collection and analysis within a behavioral health organization is preferred, but not required.

Preferred Licensure/Certification:

National Certified Investigator & Inspector Training and Certification is preferred.

PHYSICAL REQUIREMENTS:

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists, and fingers.
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
• Mental concentration is required in all aspects of work.

RESIDENCY REQUIREMENT: This position is required to reside in North Carolina or within 40 miles of the North Carolina border.

SALARY: Depending on qualifications & experience of candidate. This position is non-exempt and is eligible for overtime compensation.

DEADLINE FOR APPLICATION: Open Until Filled

APPLY: Vaya Health accepts online applications in our Career Center, please visit

Vaya Health is an equal opportunity employer.