Behavioral Health Clin Qual Audit Analyst Sr

Behavioral Health Clinical Quality Audit Analyst Sr - Massachusetts *Candidate Must Reside in the state of Massachusetts . Location: Virtual - This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law. A proud member of the Elevance Health family of companies, Carelon Behavioral Health uses our powerful combination of experience, expertise, dedication and compassion to see what's possible and what's better. Born out of one of the largest healthcare systems organization in the United States, our rich history gives us a unique and valuable perspective on how to solve the most pressing healthcare challenges. Work Shift: Monday – Friday, 8:30 am to 5:00 pm (EST) The Behavioral Health Clinical Quality Audit Analyst Sr is responsible for supporting behavioral health clinical quality, member safety, and contractual reporting requirements, including investigation of Potential Quality of Care concerns and Behavioral Health Reportable Adverse Incidents.  How you will make an impact: Serves as the dedicated Ombudsman Liaison for the Massachusetts Behavioral Health Partnership (MBHP) membership, coordinating with internal and external stakeholders to investigate and resolve member concerns and quality-of-care issues in accordance with contractual requirements and standards practices. Conducts Potential Quality of Care and member safety investigations, applies established clinical criteria, determines appropriate case disposition, and refers cases to the BH Medical Director for review and determination as indicated. Reviews Behavioral Health Reportable Adverse Incidents and ensures accurate, timely submission of required same-day state reports and associated incident rosters in accordance with contractual requirements 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.  Performs monthly, quarterly, annual and ad hoc medical record reviews. Prepares cases for Peer Review Committee and collaborates with BH clinical leadership on member safety determinations, corrective actions, and follow-up.  Travels to worksite and other locations as necessary.

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.  Active, current independent behavioral health clinical licensure such as either a LMHC, LICSW, LMFT or equivalent in the state of Massachusetts is required .