Looking for a way to make an impact and help people?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 person’s 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.
SUCCESS PROFILEWork Experience: A minimum of 5 years behavioral health experience required with a minimum of 3 years health plan experience focused on quality management/assurance/improvement, program development, and regulatory compliance auditing experience required.Education, Certificates, Licenses: A Master's degree in counseling, psychology, social work, or a related field is required. Counseling, social work, or other behavioral health licensure is also required.Knowledge: Knowledge of behavioral health State Medicaid and Medicare regulations. Knowledge of CPT, HCPCS, and ICD-10 coding. Strong analytical and problem-solving skills. Proficiency with computer information systems and software. Basic statistics and research methods.Competencies:Building TrustBuilding a Successful TeamAligning Performance for SuccessBuilding Customer LoyaltyBuilding Strategic Work RelationshipsContinuous ImprovementDecision MakingFacilitating ChangeLeveraging DiversityDriving for ResultsEnvironment: Work inside in a general office setting with ergonomically configured equipment. Evening meeting attendance is required at least monthly. Travel is required approximately 10% of the time with some overnight travel.Skills: Accountable leadership, Collaboration, Communication (written/verbal), Critical Thinking, Decision Making, Influencing, Listening (active), Organizational skills/Planning and OrganizationOur ValuesWe live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:
We are committed to doing the right thing.
We are one team working toward a common goal.
We are each responsible for customer service.
We practice open communication at all levels of the company to foster individual, team and company growth.
We actively participate in efforts to improve our many communities-internally and externally.
We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
We encourage creativity, innovation, and the pursuit of excellence.
Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.
