Behavioral Health Provider Quality Manager - Southern California

Behavioral Health Provider Quality Manager - Southern California

The Provider Quality Manager 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 Carelon members. Drives BH provider performance improvement year over year through education and data. This role is responsible for a local market.

How will you make an impact:

• 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.
• Build positive working relationships with providers, state agencies, advocacy groups, and other market stakeholders.
• Meets routinely with strategic providers face to face, telephonically, and via Web-Ex to support provider training on Carelon processes, contracting / credentialing and linkages for issue resolution, helping to improve provider experience and overall satisfaction with Carelon.
• Acts as a liaison between strategic providers and Carelon clinical, quality, provider strategy, operations, and claims, to ensure interdepartmental collaboration and coordination of goals and priorities.
• Supports regional and corporate initiatives regarding Carelon Select Provider (CSP) program, clinical innovation, and thought leadership transforming provider relationships from transactional interactions to collaboration.
• Creates and maintains linkages between providers of all levels of care, as well as other community-based services and resources to improve transitions of care and continuity of services.
• Partners with network providers and Carelon stakeholders to operationalize innovative programs and online resources 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 incentives or payment models.
• Participates in the identification of opportunities for expansion and development of innovative pilot programs, implementation, launch, and efficacy and outcomes measurements.
• Contributes to the identification of 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 quarterly physician record reviews or as needed with network providers across all service levels.
• Assists with provider orientations and provider training events in the region, when applicable.
• Attends all accessible County BH provider meetings either in person or via telephone or Web-ex.

Minimum requirements:

• Requires MA/MS or above in Behavioral Health field and a minimum of 10 years of progressively responsible professional experience in healthcare which includes a minimum of 5 years' experience in a behavioral health setting, either provider or payer; 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 (as allowed by applicable by state laws) is required.

Preferred Skills, Capabilities, and Experiences:

• Candidates who live in the Ventura or Los Angeles area HIGHLY preferred.
• Behavioral Health experience preferred.
• Travels to the worksite and other locations as necessary preferred.
• Managed care experience preferred.

Location: California