Provider Quality Manager

Provider Quality Manager

Requirements

• Requires MA/MS or above in Behavioral Health field and a 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.

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.
• Build positive working relationships with providers, state agencies, advocacy groups, and other market stakeholders.
• Meets routinely with strategic providers face to face, telephonically, and via Web-Ex to support provider training on Carelon processes, contracting / credentialing and linkages for issue resolution, helping to improve provider experience and overall satisfaction with Carelon.
• Acts as a liaison between strategic providers and Carelon clinical, quality, provider strategy, operations, and claims, to ensure interdepartmental collaboration and coordination of goals and priorities.
• Supports regional and corporate initiatives regarding Carelon Select Provider (CSP) program, clinical innovation, and thought leadership transforming provider relationships from transactional interactions to collaboration.
• 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 stakeholders to operationalize innovative programs and online resources 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 incentives or payment models.
• Participates in the identification of opportunities for expansion and development of innovative pilot programs, implementation, launch, and efficacy and outcomes measurements.
• Contributes to the identification of 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 quarterly physician record reviews or as needed with network providers across all service levels.
• Assists with provider orientations and provider training events in the region, when applicable.
• Attends all accessible County BH provider meetings either in person or via telephone or Web-ex.

Preferred Qualifications

• Travels to the worksite and other locations as necessary preferred.
• Managed care experience preferred.