Position Specific Details: This position will be responsible for working with emergency room providers and behavioral health providers in Ventura County, CA. This is a hybrid role where the successful hire will visit providers weekly in person and be expected to work in office 1+x a week.
The Behavioral Health Provider Quality Manager (PQM) 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 the Ventura County, CA market. The PQM will work with Gold Coast Health Plan providers only focused primarily on quality improvement and performance improvement specific to HEDIS FUM and FUA as well as expanding integrated care and BH services offered in schools. Additionally, the PQM will support the contracting and implementation of various value-based payment (VBP) models.
Primary duties may include but are not limited to:
- 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 through positive working relationships with providers, state agencies, advocacy groups and other market stakeholders. Meets with providers face to face, telephonically and via Web-Ex.
- Acts as a liaison between strategic providers and Beacon clinical, quality, provider strategy, network departments, operations, claims and provider relations to ensure interdepartmental collaboration and coordination of goals and priorities and to support linkages for issue resolution, helping to improve provider experience and overall satisfaction with Beacon.
- Supports regional and corporate initiatives regarding Alternative Payment Models (APM), including Value Based Payment (VBP), clinical innovation, and thought leadership transforming provider relationships from transactional interactions to collaborative aggregate data assessment.
- 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 Beacon stakeholders to operationalize innovative programs and strategies 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 or payment models.
- Collaborates with regional leadership and network teams to identify providers who are best suited for APMs, preferred provider networks, and/or other aggregate data management programs.
- Participates in the identification of opportunities for expansion and development of innovative pilot programs, to include program development, implementation, launch, and efficacy and outcomes measurements.
- Contributes to the identification of best practices and integrates 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 medical record reviews annually or as needed with network providers across all service levels.
- Assists with provider orientations and provider training events in the region, when applicable.
- Requires MA/MS or above in Behavioral Health field and 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.
- Travels to worksite and other locations as necessary.
- Managed care experience preferred.
For candidates working in person or remotely in the below locations, the salary* range for this specific position is $69,600 to $125,280
In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws .
* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.
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.
Elevance Health operates in a Hybrid Workforce Strategy, providing various levels of flexibility while also ensuring that associates have opportunities to connect in-person. Unless in a designated virtual-eligible role and 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. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.
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 firstname.lastname@example.org for assistance.