Behavioral Health QI Lead - Remote/Hybrid

Centene Corp.; United States; Hybrid; USD 46,000 - 84,000; Full time

Benefits offered by this job

Competitive pay

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Flexible work arrangements (remote,hyb

Job summary

Centene Corp. in the United States seeks a Clinical Quality Improvement professional to analyze, develop and monitor clinical QI activities, review appeals for medical necessity, and lead behavioral health quality initiatives.

You will implement a comprehensive quality program, oversee HEDIS measures, and manage records to NCQA and state standards. The role includes leading PIPS and resolving grievances with flexibility for remote, hybrid, or field/worksite arrangements.

Qualifications

• Associate's Degree in Nursing or related field required.
• 2+ years in Clinical Nursing or Behavioral Health required.
• 1+ years experience in Quality, Managed Care or Healthcare Administration required.
• Experience in Behavioral Healthcare field preferred.

Responsibilities

• Analyze, develop and monitor clinical QI activities to ensure compliance with customer expectations and lead clinical quality initiatives.
• Review clinical information for appeals to determine medical necessity of services, prepare reviews for cases, act as the liaison for appeals and fair hearings.
• Develop and implement the quality program description, work plan goals including HEDIS measures and program evaluation for behavioral health.
• Lead Behavioral Health Performance Improvement Projects (PIPS).
• Review clinical information for appeals to determine medical necessity.
• Prepare cases for appeals that do not meet medical necessity.
• Maintain files, logs, and documentation in accordance with NCQA and State standards and regulations including timelines.
• Investigate and resolve behavioral health quality of care complaints and grievances.

Skills

Clinical nursing

Quality management

Healthcare administration

Behavioral health experience

Education

Associate's degree in Nursing or related field

Job description

Centene Corp. in the United States seeks a Clinical Quality Improvement professional to analyze, develop and monitor clinical QI activities, review appeals for medical necessity, and lead behavioral health quality initiatives.

You will implement a comprehensive quality program, oversee HEDIS measures, and manage records to NCQA and state standards. The role includes leading PIPS and resolving grievances with flexibility for remote, hybrid, or field/worksite arrangements.