Behavioral Health Clinical Quality Audit Analyst Sr.

LOCATION: This is a field role covering the southwest region of Pennsylvania. Travel within this area is required. When you are not in the field, you will work virtually from your home.

HOURS: General business hours, Monday through Friday.

Field: 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 accommodation is granted as required by law. 

The Behavioral Health Clinical Quality Audit Analyst Sr. is responsible for participating in on-site quality external audits such as NCQA, AAHC and EQRO, and prepares audits of required documents.

Primary duties may include, but are not limited to:

• Conducts quality of care investigations and using criteria closes case appropriately or refers to BH Medical Director for further review.

• Prepare verbal and written case summaries, develop and utilize tracking tools, and draft executive summaries that clearly describe findings, strengths, and opportunities for improvement, maintaining accurate and timely documentation of investigations, complaint records, and supporting materials to meet required timelines

• Prepares cases for Peer Review Committee.

• Prepare clear, individualized decision letters and other formal written communications.

• Defines opportunities for improvement through trend analysis and communicates information appropriately.

• Assists in implementation and monitoring of quality studies including, but not limited to the development and implementation of behavioral health outcomes improvement interventions such as newsletter article, member education and outreach interventions, provider education and outreach interventions, medical record review, focus studies and surveys.

• Performs monthly, quarterly, annual and ad hoc medical record reviews such as HEDIS and CPG compliance.

Required Qualifications

• Requires MS/MA degree in behavioral health or related field and a minimum of 3 years experience in quality improvement and/or behavioral health, risk management and/or utilization review in a managed care setting as well as process improvement; or any combination of education and experience which would provide an equivalent background.

• Current active unrestricted license such as LCSW, LMSW, LMHC, LPC, LBA (as allowed by applicable state laws), LMFT, RN or Clinical Psychologist to practice as a health professional within the Commonwealth of Pennsylvania is required.

Preferred Qualifications

• You should be highly organized and have a very strong attention to detail.

• Experience with formal written communication is strongly preferred.

• Proficiency working within electronic health records and medical records documentation is needed for this role.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

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.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.