JR152864 Behavioral Health Clinical Quality Audit Analyst Sr

This role is primarily focused on conducting medical record reviews of facilities and clinics in our network.  The candidate must be willing and able to travel throughout Pennsylvania and surrounding areas to conduct on-site medical record reviews at participating facility locations. Additional responsibilities may include conducting investigations into potential quality of care concerns, participating in on-site quality external audits such as NCQA, Department of Human Services, and EQRO, and drafting written summaries of findings to be shared with providers.

Location: 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.

How you will make an impact:

• Performs monthly, quarterly, annual and ad hoc medical record reviews such as ASAM monitoring, HEDIS and Clinical Practice Guideline (CPG) compliance.

• Coordinates site visit dates with internal and external participants.

• Contributes to the development and revision of audit tools for mental health and substance use disorder services.

• Prepares and sends formal written correspondence in alignment with Company policies and procedures.

• Maintains workplan to ensure all required activities are completed within required timeframes.

• Provides recommendations for quality improvement studies including selection of valid and reliable indicators and coordinates monitoring and evaluation activities upon select implementation.

• Analyzes data and prepares concise, accurate and meaningful quality management reports in accordance with Company procedures.

• 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.

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

• Travels to worksite and other locations regularly (anticipated travel is 50-75%).

Minimum Requirements:

• 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.

Preferred Skills, Capabilities, and Experiences:

• Current, unrestricted behavioral health license (LCSW, LSW, LPC or RN) in Pennsylvania.

• Experience with medical record reviews.

• Experience with formal written communication.

• Experience with project management.

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.