Behavioral Health Clin Qual Audit Analyst Sr

Elevance Health•Boston, MA

10d•$87,308 - $130,962•Remote

About The Position

The Behavioral Health Clinical Quality Audit Analyst Sr is responsible for supporting behavioral health clinical quality, member safety, and contractual reporting requirements, including investigation of Potential Quality of Care concerns and Behavioral Health Reportable Adverse Incidents. This role serves as the dedicated Ombudsman Liaison for the Massachusetts Behavioral Health Partnership (MBHP) membership, coordinating with internal and external stakeholders to investigate and resolve member concerns and quality-of-care issues in accordance with contractual requirements and standards practices. The analyst conducts Potential Quality of Care and member safety investigations, applies established clinical criteria, determines appropriate case disposition, and refers cases to the BH Medical Director for review and determination as indicated. They also review Behavioral Health Reportable Adverse Incidents and ensure accurate, timely submission of required same-day state reports and associated incident rosters in accordance with contractual requirements. Additionally, the role provides recommendations for quality improvement studies, analyzes data, prepares quality management reports, defines opportunities for improvement through trend analysis, and assists in the implementation and monitoring of quality studies. This includes performing monthly, quarterly, annual, and ad hoc medical record reviews, preparing cases for the Peer Review Committee, and collaborating with BH clinical leadership on member safety determinations, corrective actions, and follow-up. Travel to worksite and other locations as necessary is also a responsibility.

Requirements

Requires MS/MA degree in behavioral health or related field and a minimum of 3 years’ experience in quality improvement and/or behavioral health, risk management and/or utilization review in a managed care setting as well as process improvement; or any combination of education and experience which would provide an equivalent background.
Active, current independent behavioral health clinical licensure such as either a LMHC, LICSW, LMFT or equivalent in the state of Massachusetts is required.

Nice To Haves

Experience with Medicaid managed care, state contractual requirements, regulatory reporting, and time-sensitive deliverables strongly preferred.
Knowledge of behavioral health quality management, patient safety, risk management, and applicable state and federal Medicaid requirements.
Strong clinical judgment and ability to review information, identify concerns, and escalate appropriately.
Strong attention to detail, critical-thinking, analytical, and organizational skills.
Demonstrated ability to collaborate effectively with clinical, medical, operational, and other cross-functional stakeholders.
Strong written and verbal communication skills, including the ability to clearly summarize clinical information and findings.

Responsibilities

Serves as the dedicated Ombudsman Liaison for the Massachusetts Behavioral Health Partnership (MBHP) membership, coordinating with internal and external stakeholders to investigate and resolve member concerns and quality-of-care issues in accordance with contractual requirements and standards practices.
Conducts Potential Quality of Care and member safety investigations, applies established clinical criteria, determines appropriate case disposition, and refers cases to the BH Medical Director for review and determination as indicated.
Reviews Behavioral Health Reportable Adverse Incidents and ensures accurate, timely submission of required same-day state reports and associated incident rosters in accordance with contractual requirements.
Provides recommendations for quality improvement studies including selection of valid and reliable indicators and coordinates monitoring and evaluation activities upon select implementation.
Analyzes data and prepares concise, accurate and meaningful quality management reports in accordance with Company procedures.
Defines opportunities for improvement through trend analysis and communicates information appropriately.
Assists in implementation and monitoring of quality studies including, but not limited to the development and implementation of behavioral health outcomes improvement interventions such as newsletter article, member education and outreach interventions, provider education and outreach interventions, medical record review, focus studies and surveys.
Performs monthly, quarterly, annual and ad hoc medical record reviews.
Prepares cases for Peer Review Committee and collaborates with BH clinical leadership on member safety determinations, corrective actions, and follow-up.
Travels to worksite and other locations as necessary.