Vaya Health

The Physical Health PN Contract Manager is responsible for identifying and contracting with physical health providers to develop a stable provider network. This role involves negotiating contracts, analyzing financial impacts, and maintaining strong relationships with health systems. | A Bachelor's degree in Public Administration, Business, or Human Services is required, with a Master's degree preferred. Candidates should have 2-5 years of relevant network management experience, including contracting with healthcare providers. | LOCATION:  Remote – this is a home based, virtual position that operates Monday – Friday from 8:30am-5:00pm EST. Must live in North Carolina or within 40 miles of the NC border. GENERAL STATEMENT OF JOB The Physical Health PN Contract Manager identifies and contracts with physical health providers to develop the physical health provider network yielding a geographically broad access, stable network that achieves objectives for unit cost performance, and produces an affordable and predictable product for members and business partners. This role evaluates and negotiates contracts in compliance with company contract templates, reimbursement structure standards, and other key process controls.  The Physical Health PN Contract Manager initiates, negotiates, and executes physician, hospital, ancillary and/or other provider contracts and agreements for Vaya Health. This position works on problems of diverse scope and complexity ranging from moderate to complex. Strategically approach the provider community and prioritize network needs both quantitatively and qualitatively. ESSENTIAL JOB FUNCTIONS Network Management: * Responsibilities include establishing and maintaining strong business relationships with Health Systems (Hospital, Physician and Ancillary providers), and ensuring the network composition includes an appropriate distribution of provider specialties. * Negotiate and re-negotiate provider organization contract terms, payment structures, and reimbursement rates to providers.  * Analyzes financial impact of contracts and terms.  * Maintains contracts and documentation within a tracking system.  * Advises executives to develop functional strategies (often segment specific) on matters of significance.  * Function as the single point-of-contact for all on-going contractual and service issues as needed by providers * Facilitate provider education and training to increase provider familiarity and satisfaction with Vaya’s systems and strategies * Create and review trend analyses and summaries for decision-making purposes * Interface with Vaya network and department leaders to align provider development needs and projects * Study and design innovative programs to create and enhance access to care, such as jail diversion, veterans and under-served populations, * Work with provider organizations and community stakeholders to successfully implement new programs and improve member access to care. * Apply network configuration and incentive-based payment models as appropriate to improve quality and efficiency * Assist others to resolve highly complex or unusual business problems that affect major functions or disciplines * Exercises independent judgment and decision making on complex issues   regarding job duties and related tasks, and works under minimal supervision, uses independent judgment requiring analysis of variable factors and determining the best course of action.     KNOWLEDGE, SKILLS, & ABILITIES * Proficiency in analyzing, understanding, and communicating financial trends; strong customer service skills; excellent verbal and written communication skills * Ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand * Ability to understand and interpret complex information from others, including but not limited to reimbursement policy standards; exceptional Business Acumen * Ability to present to varied audiences * Ability to manage multiple priorities in a fast-paced environment; high level of proficiency in Microsoft Office applications; prior demonstrated success in provider relations with large provider groups and/or ancillary providers * Experience with multiple provider relations methodologies such as RVRBS, flat rates, case rates, per diems and tiered rates based on the intensity of service * Expert level of knowledge of CMS reimbursement methodologies     EDUCATION & EXPERIENCE REQUIREMENTS  Bachelor’s degree in Public Administration, Business or Human Services required.  Master’s degree preferred.  Must have 2-5 years of relevant network management experience including contracting with Healthcare Providers and network administration in a healthcare company.   Preferred Experience: * Extensive provider contracting skills, including contract preparation and implementation, financial analysis, and rate proposal development preferred. * Experience with Medicaid and Value Based Contracting utilizing financial modeling in making rate decisions 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: The person in this position must reside in North Carolina or within 40 miles of the NC border. SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation. DEADLINE FOR APPLICATION: Open until filled. APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/ [https://www.vayahealth.com/about/careers/].  Vaya Health is an equal opportunity employer.

The Peer Support Specialist is responsible for engaging and educating adults with serious mental illness about community-based mental health services and supported housing options. This includes facilitating in-reach visits, providing information on available services, and coordinating with other staff to ensure smooth transitions for members/recipients. | A high school diploma or GED is required, along with 1-2 years of experience working with the mental health/substance use population. Candidates must also be NC Certified Peer Support Specialists. | LOCATION:  Remote – must live in or near Vance, Franklin, Granville, or Person County, NC.  The person in this role must live in North Carolina or within 40 miles of the North Carolina border. This is a home-based position that requires community travel. GENERAL STATEMENT OF JOB Under the supervision of the Peer Support Specialist Manager, the Peer Support Specialist function is in-reach, engagement, education and support effort designed to accurately and fully inform adults who have serious mental illness (SMI) or a serious and persistent mental illness (SPMI) about community based mental health services and supported housing options including but not limited to the availability of tenancy support services and rental assistance.   Peer Support Specialist in-reach is ongoing with the goal of educating members/recipients about all community-based options, including the option to transition to supported housing, its benefits, the array of services and supports available to those in supported housing to include rental subsidy and other assistance members/recipients may need. In-reach also includes informing members/recipients about Medicaid, Special Assistance, services under the North Carolina State Plan for Medical Assistance or the State funded service array for which the members/recipients are eligible.   Peer Support Specialist in-reach also includes offering the members/recipients opportunities to meet with other members/recipients with disabilities who are living, working, and receiving services in inclusive settings.   Note: This position requires access to and use of confidential healthcare information or protected health information (PHI) as described in laws addressing patient confidentiality, including, but not limited to, the federal HIPAA law, the Confidentiality of Alcohol and Substance Use Patient Records law, 42 CFR Part 2, and various state laws. As such, the individual filling this position shall be required to be trained regarding such laws and shall be required to observe those laws in his/her capacity as an employee of Vaya Health. The individual filling this position shall also sign a confidentiality statement as an employee of Vaya Health. ESSENTIAL JOB FUNCTIONS Benchmarks: Peer Support Specialist In-Reach * Must make minimum in-reach visits per day to meet weekly visit requirements. * Must meet minimum requirements per In Reach, Transition, Diversion policy for potential transition participants per month. * Must make minimum requirements for completion of the Informed Decision-Making Tool per month * Ensure adherence to boundaries within In Reach, Transition, Diversion policy and do not provide services or supports outside of the scope of work. Monitoring * Must maintain caseload (In-Reach List) by ensuring every person has a Peer Support Specialist visit prior to reaching 90 days. Frequency of ivisits can vary within 90 days based on readiness for transition. * Will communicate with manager any upcoming events (if known) that may impact minimum requirements and will propose an alternative plan to ensure that requirements are met.  Peer Support Specialist In-Reach activities: The LME-MCO shall provide In-Reach services to applicable members/recipients no less than quarterly. Peer Support Specialist may need to occur more frequently based on the housing situation of the member/recipient. It is required that Peer Support Specialist activities be delivered by LME-MCO staff that are knowledgeable about community services and supports, including supported housing.   The LME-MCO Peer Support staff is expected to coordinate a face-to-face meeting with members/recipients and guardians as applicable to determine a member/recipient’s interest in integrated supported housing with tenancy rights and behavioral health services. Peer Support Specialist staff should make every effort to schedule visits during a time that is convenient for both the member/recipient and facility. Activities include but are not limited to: * Assessing member/recipient’s interest in supported housing * Explaining fully the benefits and financial aspects of clinically appropriate community based inclusive settings, including supported housing * Facilitating and accompanying member/recipient on site visits to permanent housing with tenancy rights * Exploring and addressing the concerns of any member/recipient who declines the opportunity to move into supported housing or who are ambivalent about moving into supported housing, despite being qualified for such housing * Reviewing housing preferences * Provide linkage to ongoing in-reach as a step-in education/exposure to the housing options and supports available * Educating member/recipient about services covered under the North Carolina State Plan for Medical Assistance, Medicaid 1915(b)(c) waiver, or the State funded service array Documentation and Reporting: All Peer Support Specialist activities should be documented and outcomes of in-reach efforts tracked to include refusals to meet with LME-MCO as well as lack of response to LME-MCO written communication about in-reach by the member/recipient or guardian. All documentation related to Peer Support Specialist in-reach should be made available to the State upon request.   Peer Support Specialist staff will participate in all necessary activities at the NC state level. The activities will include training, information sessions, and committees related to Transitions to Community Living Initiative.   Coordination planning: Peer Support Specialist staff will work in close coordination with other Vaya staff, including but not limited to Transition Coordinators, care management, and other Vaya departments to ensure smooth transitions occur and challenges and barriers to transition are addressed timely.   Other duties as assigned.     KNOWLEDGE, SKILLS, & ABILITIES General knowledge of the methods and principles of recovery and person-centered thinking is needed. Having good customer service skills are essential. The ability to establish appropriate and respectful relationships/partnerships with persons with a wide range of disabilities and their families. Includes the ability to interact professionally and effectively with persons who are upset and who disagree. Building trust, establishing rapport and using good communication skills are key for this position. Knowledge of the laws, regulations, and policies which govern human services is helpful. Knowledge about Medicaid and Special Assistance benefits, available clinical services, community supports, and supported housing is necessary. Is able to express ideas clearly and concisely orally and in writing. The ability to work effectively as a team member and under the direction of the Peer Support Specialist Manager. Additional training is required, which can be obtained after hire, in the following skills set: Assertive Engagement, Motivational Interviewing, Active Listening Skills, RENEW Transition Model, and other relevant methods of engagement. EDUCATION & EXPERIENCE REQUIREMENTS High school diploma or GED is required for this position and 1-2 years of experience working with the MH/SU population.   Licensure/Certification Required: NC Certified Peer Support Specialist     MENTAL/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: The person in 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 https://www.vayahealth.com/about/careers/ [https://www.vayahealth.com/about/careers/]. Vaya Health is an equal opportunity employer.

Provide administrative and program support for Utilization Management including managing communications, coordinating peer reviews, supporting transition of care processes, and preparing documentation for audits. | High school diploma or equivalent with 4-5 years of administrative experience or related education and experience, strong verbal and written communication skills, intermediate Microsoft Office skills, and residency within 40 miles of North Carolina border. | LOCATION: Remote – must live in/near Vaya’s catchment area in North Carolina or within 40 miles of the NC border. Must have the ability to come into Vaya's Asheville NC offfice as needed. GENERAL STATEMENT OF JOB This position provides program assistance and administrative support for the Utilization Management team. This position involves extensive work using the Administrative Health Record system(s) to coordinate care for members, beneficiaries and recipients transitioning to and from Vaya’s Health Plans and managing referrals to delegated UM vendors. In addition, the employee participates in collecting and monitoring various forms of data. The employee also interacts with members, recipients, beneficiaries, providers, stakeholders, vendors, NC Department of Health & Human Services, and the public by providing information and other forms of assistance. The employee provides an array of administrative support services to teams within Utilization Management including meeting scheduling, recording notes and minutes, and organizing document storage. This position may also provide assistance as necessary with the Transition of Care process. The incumbent must be located within a reasonable commuting distance from Vaya’s home office. Position is eligible for primarily remote work; however, incumbent must be able to work from Vaya’s office when needed as directed by supervisor and Utilization Management leadership. ESSENTIAL JOB FUNCTIONS Administrative Assistant for Utilization Management/Appeals: The position provides administrative coordination and support to help maintain, evaluates, and improves Utilization Management functions, including the management of departmental communications (e.g., email inbox, fax, and phone line/voicemail, etc.), the coordination of departmental business process, including annual internal reviews, participation in Utilization Management meetings, and development and distribution of minutes and training materials as needed. This position shares responsibility for managing the Peer Review Desk as part of the clinical peer reviews conducted during the Utilization Management review process for service authorization requests. • Gathers information for referral to peer reviewer • Organizes, sends, and tracks all assigned peer reviews to ensure timeliness of completion • Gathers completed reviews from delegated vendors and formats decisions for members’ administrative health records • Communicates with the Member Appeals Team regarding Peer Review Desk functions This position provides support for transition of care for Vaya’s members and beneficiaries by ensuring that people transitioning to and from Vaya’s Health Plan experience seamless transitions of care. Primary duties are as follows: • Liaise with Standard Plan (SP) Prepaid Health Plans (PHPs), other Tailored Plans (TPs), and Tribal Option Plan • Review prior authorizations from former insurers and ensure that UM enters authorizations to honor these • Ensure that Out of Network Agreements are executed timely to ensure continuity of care • Obtain appropriate releases of information to support continuity of care when members transfer to and from • Vaya’s plan • Outreach new members transitioning from another PHP, TP, or Tribal Option Plan • Respond timely to requests for information from other insurers or vendors • Ensure that Vaya sends appropriate documentation for high acuity members transitioning to another plan to the receiving plan Administrative Support for Utilization Management: This position supports the RN UM Clinician Supervisor and other UM leadership and staff by providing administrative and clerical functions, including support for administering Value Added Services. The employee maintains files and provides support for projects as needed. This position collects data as requested to help maintain, coordinate, and evaluate Utilization Management functions. The employee schedules, hosts, and participates in Utilization Management meetings, and develops and distributes information/minutes as needed. The employee interacts with members, beneficiaries, recipients, stakeholders, providers, vendors, and the public in providing information and addressing their questions and concerns. The employee distributes mail, monitors fax accounts, and provides coverage for staff as requested. Documentation & Audit Preparations: This position prepares documentation for reviews and audits as needed, compiling, and uploading data as specific reviews dictate. Other Duties: Other Duties as assigned. KNOWLEDGE, SKILLS, & ABILITIES This position requires excellent verbal and written skills. Additionally, it requires familiarity with a wide variety of software packages and the Administrative Health Record(s). Strong people skills are required to promote excellent communication with staff at all levels, members, and the general population. This position requires skill in organizing workflow. Ability to analyze and interpret policy and procedural guidelines is necessary. Intermediate level Microsoft Office software proficiency is required. EDUCATION & EXPERIENCE REQUIREMENTS High school diploma or equivalent and 4-5 years of progressively responsible secretarial or clerical/administrative/office management experience OR Two-year secretarial science or business administration program and 2 years of progressively responsible secretarial or clerical/administrative, office management experience OR Four-year program in a college or university preferably with major emphasis on coursework in business administration, public administration, or other related field; 1 year of experience. Preferred work experience: • Experience and/or education in the healthcare field is a plus, but not required. MENTAL/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: The person in 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 https://www.vayahealth.com/about/careers/. Vaya Health is an equal opportunity employer.

Monitor and triage quality of care concerns, conduct health and safety checks, collaborate with stakeholders, and ensure compliance with provider contracts and regulations. | Bachelor’s degree in Human Services or related field with 2+ years experience in mental health or related fields, NC Qualified Professional preferred, and CLEAR/NCIT Basic Certified Investigator certification within 9 months. | LOCATION: Remote – may live anywhere in Vaya’s catchment area in North Carolina; however, there is a preference for the Charlotte NC area. This position requires travel as needed. GENERAL STATEMENT OF JOB The Provider Quality of Care Specialist serves as a vital member of the Quality Management Department and reports directly to the Provider Quality Assurance Manager. This position plays a critical role in ensuring the delivery of safe, high-quality and compliant services across Vaya’s provider network. Key responsibilities include assessing and responding to quality-of-care concerns and completing health and safety screenings. The person in this position triages quality of care concerns entered in Vaya’s EthicsPoint database and collaborates with internal and external stakeholders to address concerns and ensure timely follow-up. This role is also responsible for appropriately escalating urgent member concerns to department leadership and contributing to the development of solutions that support member safety. This position ensures that provider services delivered are consistent with funding requirements, best practices, provider's contracts, and federal/state rules and regulations. Research, reporting, and providing technical assistance are key functions of this role to support continuous quality improvement. Additionally, this role involves coordinating and performing - in-person screenings at home and community-based settings to ensure member health and safety. ESSENTIAL JOB FUNCTIONS The incumbent in this position serves as part of a monitoring team and will work as a part of that team to complete monitoring of network providers. Responsibilities include: Triage Quality of Care Concerns and complete required follow up review activities: • Monitor and triage quality of care concerns received in Vaya’s EthicsPoint database. Review new quality of care concerns and determine appropriate follow-up action needed to address any identified issues. Follow-up actions may include, but are not limited to: • Researching provider contract requirements, State and Federal regulations, member service history, and incident report information. • Conducting outreach to request pertinent case information from providers, Vaya staff, and external stakeholders. • Staffing urgent quality of care and health and safety concerns with the Provider Quality Assurance Manager. • Escalate concerns to Quality Management leadership as appropriate. • Support work-flow management by partnering closely with the Provider Quality Assurance Manager to ensure tasks assigned to the team are complete and meet set timelines. • Report concerns to external regulatory agencies as needed. • Provide technical assistance to educate providers on contractual requirements. • Complete case notes and update all required case fields in EthicsPoint to document activities within required timelines. • Participate in multidisciplinary meetings and contribute to quality improvement initiatives as assigned. Health/Safety Checks: • Collaborate with the Provider Quality Assurance Manager to coordinate announced or unannounced Health and Safety Checks. • Conduct announced or unannounced Health and Safety checks as needed and/or assigned to assess quality of care and ensure member Health and Safety. • Complete documentation from reviews as requested • Complete announced unlicensed alternative family living (UAFLs) reviews to assess compliance with health and safety requirements for urgent and expedited placements. Serve as back up for UAFL reviews. • Review HCBS assessments for any urgent and expedited placements as assigned. Other duties as assigned: • Serve as an additional reviewer for focused reviews and investigations. • Review provider Plans of Correction as assigned. • Assist in developing dashboards and presentations for internal and external stakeholders. • Review and process Relative as Direct Support Employee (RADSE) requests as assigned. KNOWLEDGE, SKILLS, & ABILITIES Success in this position requires exceptional interpersonal skills, and highly effective communication ability. A high level of diplomacy and discretion is required to effectively negotiate and resolve issues. In addition, the person in this position must have: • Knowledge of state and federal rules, requirements and practices related to the service continuum in North Carolina. • Knowledge of policy and procedure is essential related to monitoring plans of correction and resolution. • Ability to analyze and interpret policy and procedural guidelines. • Ability to problem solve, critically think, analyze, interpret and apply data obtained and make recommendations to support member safety and business needs. • Ability to work independently with little or no direction, demonstrate initiative, and function as a self-starter. • Excellent time management skills and the ability to reprioritize in a fast-paced environment and keep up with multiple, possibly competing, priorities. • Effectively work in a complex healthcare environment in a highly collaborative manner keeping all stakeholders informed as appropriate. • A high level of diplomacy and discretion is required to effectively negotiate and resolve issues. • Strong negotiation and conflict resolution skills to manage sensitive issues and drive consensus. • Ability to establish and maintain positive and effective working relationships with others. • Experience in assigning tasks, managing workloads, and monitoring team performance to ensure quality and timeliness. • Ability to anticipate challenges, assess risks, and make informed decisions that support members’ safety and service quality. • Ability to effectively present information and respond to questions from internal and external stakeholders in a professional and concise manner. • Excellent computer skills; proficiency in Microsoft Office Suite; and experience creating documents, forms, and graphs. • Skilled in organizing workflow and strong detail orientation. • Exceptional written and verbal communication skills including excellent skills in English grammar, punctuation, and spelling, and ability to clearly communicate complex ideas and concepts EDUCATION & EXPERIENCE REQUIREMENTS • A Bachelor’s Degree in a Human Service field and two years of experience in the field of mental health, intellectual and developmental disabilities, or substance use disorders is required. OR • A Bachelor’s Degree in a field other than Human Services and six years of experience in the field of mental health, intellectual and developmental disabilities, or substance use disorders is required. Meeting the criteria of being a North Carolina Qualified professional in 10A NCAC 27G .0104 is preferred. Licensure/Certification Required: • CLEAR/NCIT Basic Certified Investigator (certification should be completed within the first 9 months of employment) Preferred work experience: • Three or more years experience in the field of mental health, intellectual and developmental disabilities, or substance use disorders is preferred. • Meeting the criteria of being a North Carolina Qualified professional in 10A NCAC 27G .0104 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: May live in Vaya's catchment area in North Carolina or within 40 miles of the North Carolina border. However, there is a preference for the Charlotte NC area. SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation. DEADLINE FOR APPLICATION: Open until filled APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/. Vaya Health is an equal opportunity employer.