Quality Performance Review and Clinical Monitoring
- Conduct quality reviews of the Medical Foster Care Program; Prescribed Pediatric Extended Care Program; Early Intervention Services; Medicaid Certified School Match Program; Project AIDS Care Waiver; Adult Cystic Fibrosis Waiver; and the Traumatic Brain and Spinal Cord Injury Waiver.
- Participate in interagency child staffing meetings for medical neglect, behavioral health services, and the Children’s Multidisciplinary Assessment Team (CMAT).
- Provide clinical reviews of managed care plan reports and initiatives.
- Perform targeted monitoring of managed care services to ensure that Medicaid enrollees receive services provided in the quantity and quality required for treatment of the enrollee’s condition, in compliance with the Statewide Medicaid Managed Care (SMMC) contract.
- Review and analyze data submitted by the SMMC plans for the Critical Incident Report – Individual; Adverse and Critical Incident Summary Report; PCP Appointment Report; ER Visits for Enrollees without PCP Appointment Report; Healthy Behaviors Report; and the Residential Psychiatric Treatment Report.