Location: Candidate must be residing Pennsylvania
Schedule: O nsite at the Fayette County office at least twice a week (9:00 AM to 5:30 PM EST)
Responsible for participating in on-site quality external audits such as NCQA, AAHC and EQRO, and prepares audits of required documents. This position supports the Fayette Co. Medicaid contract.
How you will make an impact:
- 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 for Fayette Co. Quality 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.
- Performs monthly, quarterly, annual and ad hoc medical record reviews such as HEDIS and CPG compliance.
- Conducts quality of care investigations and using criteria closes case appropriately or refers to BH Medical Director for further review.
- Prepares cases for Peer Review Committee.
- 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.
- Specific education, type of experience and/or licensure may be required based upon contract requirements and delegated responsibilities.
- Travel is required as the position is onsite at the Fayette County office at least twice a week. Additional travel to provider facilities may be required.
Preferred skills, capabilities and experiences:
- Proficiency in Excel
- Excellent written and verbal communication skills
- NCQA knowledge
Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Be part of an Extraordinary Team
Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. A Fortune 20 company with a longstanding history in the healthcare industry, we are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
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.
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. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health has been named as a Fortune Great Place To Work in 2022, has been ranked for five years running as one of the 2023 World’s Most Admired Companies by Fortune magazine, and is a growing Top 20 Fortune 500 Company. To learn more about our company and apply, please visit us at careers.ElevanceHealth.com. 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 email@example.com for assistance.