Behavioral Health Clinical Quality Audit Analyst Sr.

Elevance Health•Hermitage, PA

2d•Hybrid

About The Position

The Behavioral Health Clinical Quality Audit Analyst Sr. is responsible for participating in on-site quality external audits such as NCQA, AAHC and EQRO, and prepares audits of required documents. Primary duties may include, but are not limited to: Conducts quality of care investigations and using criteria closes case appropriately or refers to BH Medical Director for further review. Prepare verbal and written case summaries, develop and utilize tracking tools, and draft executive summaries that clearly describe findings, strengths, and opportunities for improvement, maintaining accurate and timely documentation of investigations, complaint records, and supporting materials to meet required timelines Prepare cases for Peer Review Committee. Prepare clear, individualized decision letters and other formal written communications. 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 such as HEDIS and CPG compliance.

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.
Current active unrestricted license such as LCSW, LMSW, LMHC, LPC, LBA (as allowed by applicable state laws), LMFT, RN or Clinical Psychologist to practice as a health professional within the Commonwealth of Pennsylvania is required.

Nice To Haves

You should be highly organized and have a very strong attention to detail.
Experience with formal written communication is strongly preferred.
Proficiency working within electronic health records and medical records documentation is needed for this role.

Responsibilities

Conducts quality of care investigations and using criteria closes case appropriately or refers to BH Medical Director for further review.
Prepare verbal and written case summaries, develop and utilize tracking tools, and draft executive summaries that clearly describe findings, strengths, and opportunities for improvement, maintaining accurate and timely documentation of investigations, complaint records, and supporting materials to meet required timelines
Prepare cases for Peer Review Committee.
Prepare clear, individualized decision letters and other formal written communications.
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 such as HEDIS and CPG compliance.