Quality Improvement Coordinator - Behavioral Health

Centene Management Company LLC; Los Angeles (CA); 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 schedules (remote,hybrid

Job summary

Centene Management Company LLC in Los Angeles is seeking a Clinical Quality Improvement professional to analyze, develop, and monitor clinical quality initiatives, including appeals and medical necessity reviews. You will lead HEDIS measures, NCQA-aligned documentation, and behavioral health PIPS, while ensuring compliance with state standards.

The role requires RN/LMHC/LPC-credentialed professionals with 2+ years in clinical nursing or behavioral health and 1+ year in quality or healthcare

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.

Responsibilities

• Develop and implement the quality program description, work plan goals including applicable HEDIS measures and program evaluation (trilogy documents) 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, documentation including communication in accordance with NCQA and State standards and regulations including timelines.
• Investigate and resolve behavioral health quality of care complaints and grievances.
• Performs other duties as assigned.
• Complies with all policies and standards.

Skills

Clinical nursing

Behavioral health

Healthcare administration

Quality improvement

Education

Associate's degree in nursing

Job description

Position Purpose:

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 applicable Healthcare Effectiveness Data and Information Set (HEDIS) measures and program evaluation (trilogy documents) 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, documentation including communication in accordance with National Committee for Quality Assurance (NCQA) and State standards and regulations including timelines. Investigate and resolve behavioral health quality of care complaints and grievances. Performs other duties as assigned. Complies with all policies and standards.

Education / Experience:

• Associate's Degree in Nursing or other related field of study 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.

Licenses / Certifications:

• Registered Nurse (RN) certification,
• Licensed Mental Health Professional (LMHC), or
• Licensed Professional Counselor (LPC) required.

Responsibilities:

• Develop and implement the quality program description, work plan goals including applicable Healthcare Effectiveness Data and Information Set (HEDIS) measures and program evaluation (trilogy documents) 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, documentation including communication in accordance with National Committee for Quality Assurance (NCQA) and State standards and regulations including timelines.
• Investigate and resolve behavioral health quality of care complaints and grievances.
• Performs other duties as assigned.
• Complies with all policies and standards.

Pay Range:

$33.71 - $60.67 per hour.

Benefits:

• competitive pay
• health insurance
• 401K and stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• a flexible approach to work with remote, hybrid, field or office work schedules

Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

Equal Opportunity:

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.

Centene is committed to helping people live healthier lives. We provide access to high-quality healthcare, innovative programs and a wide range of health solutions that help families and individuals get well, stay well and be well.