Behavioral Health Provider Quality Manager

Elevance Health - Jacksonville, FL

Full-time - Mid Level

Jacksonville, FL

Insurance Carriers and Related Activities

About the position

The Behavioral Health Provider Quality Manager is responsible for leading Behavioral Health (BH) provider engagement, with a focus on leveraging the data available to providers and helping to improve the value delivered to Carelon BH members. Drives BH provider performance improvement year over year through education and data. This role is responsible for a local market.

Responsibilities

• Establishes relationships and engages with BH providers and ensures measurable improvements in clinical and quality outcomes for members.
• Builds relationships with internal clinical and quality departments to ensure high quality care to members and achievement of company HEDIS performance.
• Implements strategies that meet clinical, quality, and network improvement goals through positive working relationships with providers, state agencies, advocacy groups and other market stakeholders.
• Meets with providers face to face, telephonically and via Teams.
• Acts as a liaison between strategic providers and Carelon BH clinical, quality, provider strategy, network departments, operations, claims and provider relations to ensure interdepartmental collaboration and coordination of goals and priorities and to support linkages for issue resolution, helping to improve provider experience and overall satisfaction with Carelon BH.
• Supports regional and corporate initiatives regarding Alternative Payment Models (APM), including Value Based Payment (VBP), clinical innovation, and thought leadership transforming provider relationships from transactional interactions to collaborative aggregate data assessment.
• Performs medical record and case management file reviews for enrollees who are high utilizers of CSU and inpatient psychiatric hospital services, Baker Act receiving facilities, and/or CSUs.
• Creates and maintains linkages between providers of all levels of care, as well as other community-based services and resources to improve transitions of care and continuity of services.
• Partners with network providers and Carelon BH stakeholders to operationalize innovative programs and strategies to improve clinical and quality outcomes.
• Analyzes provider reports pertaining to cost, utilization, and outcomes, and presents the data to providers and highlights trends.
• Identifies data outliers and opportunities for improvement for individual providers.
• Identifies high-performing and innovative providers who may be interested in new programmatic or payment models.
• Collaborates with regional leadership and network teams to identify providers who are best suited for APMs, preferred provider networks, and/or other aggregate data management programs.
• Participates in the identification of opportunities for expansion and development of innovative pilot programs, to include program development, implementation, launch, and efficacy and outcomes measurements.
• Contributes to the identification of best practices and integrates high-quality program ideas/designs into the local market to drive high levels of value.
• Provides consultation to providers for clinically complex members as applicable.
• Surfaces clinical and quality issues to regional clinical and quality teams and participates in helping to address concerns.
• Conducts medical record reviews annually or as needed with network providers across all service levels.
• Assists with provider orientations and provider training events in the region, when applicable.

Requirements

• Requires MA/MS or above in Behavioral Health field and minimum of 10 years of progressively responsible professional experience in healthcare which includes a minimum of 5 years' experience in a behavioral health setting, either provider or payer; or any combination of education and experience, which would provide an equivalent background.
• Current, valid, independent and unrestricted license such as RN, LCSW, LMFT, LMHC, LPC, or Licensed Psychologist (as allowed by applicable by state laws) is required.

Nice-to-haves

• Managed care experience preferred.

Benefits

• merit increases
• paid holidays
• Paid Time Off
• incentive bonus programs
• medical
• dental
• vision
• short and long term disability benefits
• 401(k) +match
• stock purchase plan
• life insurance
• wellness programs
• financial education resources