PacificSource Health Plans Behavioral Health Clinical Quality Improvement Coordinator in Eugene, Oregon
This position is responsible for design, implementation, and oversight of Behavioral Health (BH) Quality Management program and activities.This position is responsible for all aspects of the BH Quality Management program including but not limited to; development of quality assurance and improvement plans, internal and external quality auditing, and delegated vendor monitoring assuring compliance with State and Federal regulatory standards, contractual requirements, and delivery of high quality clinical care.The position also analyzes effectiveness of programs, clinical services and processes and implements changes for improvementto PacificSource Community Solutions (PSCS) behavioral health programs and services.
Develop the BH Quality Work Plan in collaboration with subcontracted delegated entities and providers incorporating assurance activities and improvement initiatives.
Analyze BH quarterly Quality Work Plan reports and presents results and written analysis to the Quality Assurance and Utilization Management Committee.
Develop and manage a continuous contract auditing and monitoring process for BH services and programs to comply with state, federal, and contract requirements.
Responsible for coordinating delegated vendor oversight, establishing infrastructure and operational mechanisms to ensure ongoing vendor compliance
Develop auditing, monitoring tools, performance measures/indicators and reporting processes that are relevant to contracts and consistent with state and federal regulations.
Continuously monitor compliance and performance standards mandated by our State contract and other regulatory bodies as those pertain to PSCS BH services and programs.
Develop, implement and monitor 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.
Continuously monitor compliance and performance standards of our subcontracted delegated entities and providers.
Review critical incidents for quality of care and process improvement opportunities.
Ensure delegated vendors and providers submit and execute corrective action plans as required.
Design, write, and present specialized quality reports.
Provide assistance to meet Quality Incentive Metrics involving behavioral health.
Manage maintenance of BH policies, procedures, and documents related to BH quality management and compliance. Ensure annual review timelines are met and policies and procedures are relevant, up to date and compliant.
Answer PSCS BH contract interpretation questions from other departments, physicians and providers of medical services and supplies.
Work with department leadership in responding to inquiries or complaints to the Insurance Commission, preparing reports for other review functions, and addressing grievances and appeals.
Coordinate business activities by maintaining collaborative partnerships with key departments.
Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.
Meet department and company performance and attendance expectations.
Lead and/or support quality improvement activities, designated committees, and/or task forces to ensure the delivery of quality, cost-efficient, high quality member care.
Build partnerships by interfacing with community stakeholders and provider community to promote all aspects of high quality clinical care.
Represent PSCS in quality capacity at community, statewide and regional meetings to create and implement quality improvement policy, projects and interventions.
Perform other duties as assigned.
Work Experience:A minimum of 3 years behavioral health experience required. Psychiatric and substance abuse health care preferred. Quality management/assurance/improvement, project development, management and implementation, and/or regulatory compliance auditing required.
Education, Certificates, Licenses: Master's degree required in counseling, psychology, social work, or related field or a Registered Nurse with behavioral health care experience. License/certification in behavioral health related field preferred.
Knowledge: Knowledge of behavioral health State Medicaid and Medicare regulations. Strong analytical and problem solving skills. Proficiency with computer information systems and software.Basic statistics and research methods.
Building Customer Loyalty
Building Strategic Work Relationships
Contributing to Team Success
Planning and Organizing
We are committed to doing the right thing.
We are one team working toward a common goal.
We are each responsible for our customers’ experience.
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 communities-internal and external.
We encourage creativity, innovation, continuous improvement, and the pursuit of excellence.
Environment:Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately5%of the time.
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.
Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.
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.
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, national origin, sex, sexual orientation, gender identity or age.