Job Details

Behavioral Health Clinical Quality Improvement Program Manager

Join PacificSource and help our members access quality, affordable care! PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each persons talents and strengths.

This position is responsible for overseeing the Behavioral Health (BH) Clinical Quality Improvement program. This position provides leadership and supervision to the behavioral health quality staff through project support, guidance, and mentorship. This position is accountable for all aspects of the BH Clinical Quality Improvement program including but not limited to: developing quality assurance and improvement plans, conducting quality audits, and monitoring providers to ensure compliance with regulatory standards, payment integrity, contractual requirements, and delivery of high-quality care.

Essential Responsibilities

• Develop and manage a continuous contract auditing and monitoring process for BH services and programs to comply with state and federal requirements.
• Provide supervision, training, and support to Behavioral Health Clinical Quality Improvement team.
• Conduct performance management and assist with hiring, staff development, and termination of employees.
• Support Leader Standard Work through setting goals and metrics, visual management, idea boards, huddles, one-on-ones with team members and regular team meetings.
• Develop auditing and monitoring tools, performance measures/indicators, and reporting processes relevant to contracts and consistent with state and federal regulations.
• Actively participate as a key team member in department and inter-department meetings and retreats.
• Conduct claims reviews utilizing data analytic tools to identify aberrant billing patterns and develop referral reports for further investigation by the Compliance department.
• Oversee and assist the team with BH provider auditing and monitoring of services and programs to ensure compliance with state, federal, and contract requirements.
• Provide oversight and assist team with BH corrective action plans in response to internal and external audits. Ensure timely submission and execution of corrective actions resulting in compliance with State and Federal regulations and contract requirements.
• Accountable for the development of the BH Quality Work Plan, incorporating quality assurance activities and improvement initiatives reported out through the Behavioral Health Clinical Quality and Utilization Management Committee.
• Oversee and analyze effectiveness of programs, clinical services, and processes and implement changes to improve behavioral health programs and services.
• Provide leadership to quality activities and discussions where clinical expertise is required.
• Continuously monitor compliance and performance standards mandated by State contract and other regulatory bodies regarding BH services and programs.
• Collaborate with the Special Investigations Unit during Fraud, Waste, and Abuse investigations, serving as a subject matter expert on clinical processes and BH rules and regulations.
• Develop and manage BH policies, procedures, and documents related to BH clinical quality and compliance. Ensure annual review timelines are met, and policies and procedures are relevant, up-to-date, and compliant.
• Design, write, and present specialized quality reports.
• Review critical incidents to identify quality of care concerns and opportunities for quality improvement.
• Lead and/or support quality improvement activities, designated committees, and/or task forces to ensure the delivery of high-quality, cost-efficient member care.
• Build partnerships by interfacing with community partners and provider community to promote all aspects of high-quality clinical care.

Supporting Responsibilities

• Represent PacificSource in quality capacity at community, statewide, and regional meetings to create and implement quality improvement policies, projects, and interventions.
• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

Work Experience: A minimum of 5 years behavioral health experience required with a minimum of 3 years health plan experience focused on quality management/assurance/im