Chief Behavioral Health & Quality Officer

Presbyterian Healthcare Services

9d•Remote

About The Position

The leader of Quality & Behavioral Health serves as the strategic and external-facing leader for behavioral health initiatives and programs impacting children in state custody, while also owning risk adjustment strategy and quality performance for behavioral health and related populations across all lines of business within the Presbyterian Health Plan. This role builds strong partnerships with state agencies, providers, and community organizations to advance behavioral health systems of care; ensures compliant operations in accordance with contractual and court-mandated directives; directs behavioral health vendor performance; and leads the development and implementation of crisis continuum and integrated behavioral health models. This leader ensures clinical quality, risk score accuracy, encounter data integrity, financial performance, and member satisfaction goals are met, while promoting health equity and population health across Medicaid, Medicare, and Commercial products.

Requirements

Bachelors degree required
Minimum 8–10 years of experience in healthcare, BH, CISC, Medicaid roles.
Expertise in health plan operations, regulatory programs, government relations, and vendor management.
Demonstrated experience leading risk adjustment operations and analytics for one or more lines of business.
Excellent leadership, communication, and internal and external stakeholder management skills.

Nice To Haves

Master’s degree in Public Health, Health Administration, Social Work, Psychology, or related field.
Certification(s): CRC (Certified Risk Adjustment Coder) or CPC, plus clinical coding and compliance training.
Hands-on experience with encounter data submissions (e.g., EDS/EDPS/RAPS) and error remediation.
Familiarity with NCQA accreditation standards and CMS/HHS risk adjustment regulations.
Experience designing or managing value-based payment arrangements for behavioral health providers.

Responsibilities

Ensure compliant operation of PHP’s Children in State Custody program and manage reputational risk.
Develop proactive monitoring processes for CISC and behavioral health contractual requirements.
Build and maintain outreach strategies with key stakeholders, including providers and community organizations.
Identify opportunities and risks related to behavioral health priorities and lead responsive initiatives.
Oversee behavioral health vendor performance, ensuring integration of clinical services and contractual compliance.
Lead implementation of behavioral health initiatives, including crisis continuum and clinical programs.
Represent PHP in external engagements, including serving as primary contact for Kevin S. Settlement matters.
Collaborate with VP Population Health & Quality and Chief Medical Officer to advance integrated care models.
Develop and maintain a statewide behavioral health network.
Work with product leads (Medicare, Commercial, Medicaid) to optimize behavioral health benefit design.
Ensure compliance with state and federal regulations, contractual requirements, and NCQA accreditation standards.
Oversee behavioral health reporting for all lines of business and maintain quality performance metrics.
Promote behavioral health managed care concepts and cost-of-care strategies within the community.
Develop policies, procedures, and workflows for all managed behavioral health functions.
Provide leadership for staff development, training, and succession planning within the Behavioral Health Department.
Own the health plan’s risk adjustment strategy and results for behavioral health and CISC-related populations across Medicaid, Medicare Advantage, and Commercial/Exchange lines of business.
Drive accurate, compliant diagnosis capture (e.g., HCCs) through provider documentation education, coding integrity programs, and collaboration with care management and quality teams.
Establish a behavioral health coding integrity program that includes prospective, concurrent, and retrospective reviews; monitor for compliance with CMS/HHS and state regulations, and prevent any upcoding or inappropriate practices.
Lead encounter data and risk submission operations (e.g., EDS/EDPS/RAPS as applicable) in partnership with IT and vendors; resolve submission errors and ensure high acceptance rates.
Develop suspect-driven outreach and measurement-based care workflows to identify and confirm chronic behavioral health diagnoses and comorbidities.
Partner with Healthcare Value Leader to integrate risk adjustment with Quality/HEDIS and Stars strategies to align interventions (e.g., follow-up after ED visit for mental illness, antidepressant medication management) with documentation and care outcomes.
Create monthly RAF dashboards with drill-down by provider, region, product, and cohort (including CISC); track acceptance rates, coding accuracy, and documentation timeliness.
Negotiate and govern vendor/partner contracts (including delegated BH vendors) with clear SLAs for risk adjustment, encounter data, analytics, and provider enablement.
Lead provider engagement programs (training, toolkits, onsite/virtual consultations) to improve documentation quality for BH and pediatric complex cases; include measurement-based care and standardized screening tools.
Monitor regulatory changes to risk adjustment models (CMS-HCC, HHS-HCC, state Medicaid models) and proactively update workflows, training, and system configurations.
Coordinate cross-functional risk adjustment steering committee (Finance, Network, Quality, Clinical Ops, Compliance, IT) to ensure alignment and oversight.