Quality Improvement Coordinator - Behavioral Health
About The Position
You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. Work Location & Licensing Requirements This is a remote position. Candidates must reside in and hold an active professional license in the state of Washington to be considered. Required Licensure Candidates must hold one (1) of the following active licenses: Registered Nurse (RN) – behavioral health experience required Licensed Clinical Social Worker (LCSW) Licensed Mental Health Counselor (LMHC) Licensed Professional Counselor (LPC) Master of Social Work (MSW) Licensed Marriage and Family Therapist (LMFT) Licensed Professional Clinical Counselor (LPCC/CC) Chemical Dependency Professional (CDP) Position Purpose: Analyze, develop and monitor clinical QI activities to ensure compliance with customer expectations and lead clinical quality initiatives. Review clinical information for appeals to determine medical necessity of services, prepare reviews for cases, act as the liaison for appeals and fair hearings. Develop and implement the quality program description, work plan goals including applicable Healthcare Effectiveness Data and Information Set (HEDIS) measures and program evaluation (trilogy documents) for behavioral health Lead Behavioral Health Performance Improvement Projects (PIPS) Review clinical information for appeals to determine medical necessity Prepare cases for appeals that do not meet medical necessity Maintain files, logs, documentation including communication in accordance with National Committee for Quality Assurance (NCQA) and State standards and regulations including timelines Investigate and resolve behavioral health quality of care complaints and grievances Performs other duties as assigned Complies with all policies and standards For Coordinated Care - Washington only: A degree in Nursing or other related field of study. 2+ years experience in Behavioral Health 1+ year of experience in Quality, Managed Care or Healthcare Administration required Experience in Behavioral Healthcare field required Required Licensure Candidates must hold one (1) of the following active licenses: Registered Nurse (RN) – behavioral health experience required Licensed Clinical Social Worker (LCSW) Licensed Mental Health Counselor (LMHC) Licensed Professional Counselor (LPC) Master of Social Work (MSW) Licensed Marriage and Family Therapist (LMFT) Licensed Professional Clinical Counselor (LPCC/CC) Chemical Dependency Professional (CDP)
Requirements
- Candidates must reside in and hold an active professional license in the state of Washington to be considered.
- 2+ years experience in Behavioral Health
- 1+ year of experience in Quality, Managed Care or Healthcare Administration required
- Experience in Behavioral Healthcare field required
- Registered Nurse (RN) – behavioral health experience required
- Licensed Clinical Social Worker (LCSW)
- Licensed Mental Health Counselor (LMHC)
- Licensed Professional Counselor (LPC)
- Master of Social Work (MSW)
- Licensed Marriage and Family Therapist (LMFT)
- Licensed Professional Clinical Counselor (LPCC/CC)
- Chemical Dependency Professional (CDP)
- A degree in Nursing or other related field of study.
Responsibilities
- Analyze, develop and monitor clinical QI activities to ensure compliance with customer expectations and lead clinical quality initiatives.
- Review clinical information for appeals to determine medical necessity of services, prepare reviews for cases, act as the liaison for appeals and fair hearings.
- Develop and implement the quality program description, work plan goals including applicable Healthcare Effectiveness Data and Information Set (HEDIS) measures and program evaluation (trilogy documents) for behavioral health
- Lead Behavioral Health Performance Improvement Projects (PIPS)
- Review clinical information for appeals to determine medical necessity
- Prepare cases for appeals that do not meet medical necessity
- Maintain files, logs, documentation including communication in accordance with National Committee for Quality Assurance (NCQA) and State standards and regulations including timelines
- Investigate and resolve behavioral health quality of care complaints and grievances
- Performs other duties as assigned
- Complies with all policies and standards
Benefits
- competitive pay
- health insurance
- 401K and stock purchase plans
- tuition reimbursement
- paid time off plus holidays
- a flexible approach to work with remote, hybrid, field or office work schedules
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
