Quality Improvement Coordinator - Behavioral Health
Core
Analyze, develop, and monitor clinical quality improvement (QI) activities for behavioral health services, including reviewing clinical information for appeals to determine medical necessity.
Role type
Quality Improvement Coordinator (Behavioral Health)
Builds
Behavioral health quality programs and performance improvement projects (PIPS) aligned with HEDIS measures and NCQA standards.
Domain
Behavioral Health / Managed Care
Required skills
Clinical nursing or behavioral health expertise, Quality/Managed Care/Healthcare Administration experience, Medical necessity determination, Appeals and fair hearings liaison, Regulatory compliance (NCQA/State standards), Complaint and grievance resolution
Preferred skills
Experience in Behavioral Healthcare field
Technologies
HEDIS measures, Trilogy documents, NCQA standards
Responsibilities
Develop and implement quality program descriptions and work plan goals; Lead Behavioral Health Performance Improvement Projects (PIPS); Review clinical information for appeals; Prepare cases for appeals; Maintain files and documentation per regulations; Investigate and resolve quality of care complaints and grievances
Seniority
Mid-level, hands-on IC