Behavioral Health Quality Improvement Lead (Remote)

Louisiana Healthcare Connections, Inc.; Baton Rouge (LA); On-site; USD 46,000 - 84,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off and holidays

Flexible work schedules

Job summary

Centene is seeking an experienced Quality Improvement professional in Louisiana to analyze, develop and monitor clinical QI activities, ensuring compliance with customer expectations and leading behavioral health initiatives. The role includes reviewing clinical information for medical necessity in appeals, preparing cases for appeals, and coordinating with NCQA/state standards.

The candidate will maintain documentation, lead PIPS for Behavioral Health, and resolve quality-of-care complaints

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.
• Registered Nurse (RN) certification, LMHC, or LPC required.

Responsibilities

• Analyze, develop and monitor clinical QI activities to ensure compliance with customer expectations and lead quality initiatives.
• Review clinical information for appeals to determine medical necessity of services.
• Prepare reviews for cases and act as liaison for appeals and fair hearings.
• Develop and implement the quality program description, work plan goals including applicable HEDIS measures and program evaluation for behavioral health.
• Lead Behavioral Health Performance Improvement Projects (PIPS).
• Maintain files, logs, and documentation per NCQA and state standards including timelines.
• Investigate and resolve behavioral health quality of care complaints and grievances.
• Complies with all policies and standards.

Skills

Clinical Nursing

Behavioral Health

Quality

Education

Associate's Degree in Nursing

Related field of study

Job description

Centene is seeking an experienced Quality Improvement professional in Louisiana to analyze, develop and monitor clinical QI activities, ensuring compliance with customer expectations and leading behavioral health initiatives. The role includes reviewing clinical information for medical necessity in appeals, preparing cases for appeals, and coordinating with NCQA/state standards.

The candidate will maintain documentation, lead PIPS for Behavioral Health, and resolve quality-of-care complaints