Behavioral Health Provider Quality Manager (field)

Elevance Health • Seven Fields, PA

4d • Hybrid

About The Position

Behavioral Health Provider Quality Manager LOCATION: This is a field role covering northwestern and southwestern Pennsylvania. When you are not in the field, you will work virtually from your home. HOURS: General business hours, Monday through Friday. TRAVEL: Travel is required throughout your assigned area(s). This field-based role enables associates to primarily operate in the field, traveling to client sites or designated locations as their role requires, with occasional office attendance for meetings or training. This approach ensures flexibility, responsiveness to client needs, and direct, hands-on engagement. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. This individual contributor role 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 members. Drives BH provider performance improvement year over year through education and data. This role is responsible for a local market. Primary duties may include, but are not limited to: 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 organization to ensure interdepartmental collaboration and coordination of goals. Supports regional and corporate initiatives regarding Alternative Payment Models (APM), including Value Based Payment (VBP), clinical innovation, and thought leadership. Creates and maintains linkages between providers of all levels of care, as well as other community-based services and resources. Partners with network providers and organization 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. 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 in a Behavioral Health field and minimum of 10 years of professional experience in healthcare which includes a minimum of 5 years experience in a behavioral health setting; 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 issued by the Commonwealth of Pennsylvania is required.

Nice To Haves

• Previously quality experience is very helpful.
• Experience analyzing and interpreting data is preferred.
• Proficiency in Microsoft applications, especially Excel, is strongly preferred.
• Managed care experience preferred.

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 organization to ensure interdepartmental collaboration and coordination of goals.
• Supports regional and corporate initiatives regarding Alternative Payment Models (APM), including Value Based Payment (VBP), clinical innovation, and thought leadership.
• Creates and maintains linkages between providers of all levels of care, as well as other community-based services and resources.
• Partners with network providers and organization 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.
• 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.

Benefits

• We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level