Resp & Qualifications
CareFirst BlueCross BlueShield (CareFirst), is the Mid-Atlantic region’s largest health plan, covering the healthcare needs of 3.4 million members. With the implementation of its Patient Centered Medical Home (PCMH) Program, CareFirst is a national leader in clinical innovation and quality programs. The company’s Total Care and Cost Improvement (TCCI) Programs support members along the care continuum, as they progress through various stages of health and illness for both medical and behavioral health.
Integrating needed medical and Behavioral Health services into a coherent plan of care over an extended time period is critical to improving overall health outcomes and reducing costs.
The Behavioral Health Quality Specialist is part of a team responsible for helping to ensure that our 3.4 million members receive the highest quality care and service possible. This individual, in collaboration with others across the organization, is responsible for quality measurement collection and will use data to identify opportunities and work throughout the organization to implement quality improvement interventions.
This individual champions quality improvement across the company for behavioral health. Through relationships with key leads throughout the organization, they carry out the QI Program goals and objectives leading to compliance with regulatory and accreditation requirements and progressively increasing health plan performance and patient outcomes.
This individual is a part of a team of quality professionals to achieve the triple aim: improving health outcomes, reducing cost of care and improving the overall experience for members; as well as, physician satisfaction through the following:
- Carries out the region-wide quality improvement (QI) program;
- Collects, analyzes and reports on mandated quality assessments; and
- Leads Behavioral Health Quality Improvement activities.
Under the direct supervision of the Manager, Quality and Regulatory Compliance, this associate’s accountabilities include, but are not limited to, the following:
1. Carries out the corporate QI program
The Behavioral Health Quality Specialist, utilizes healthcare knowledge, business acumen and data fluency to drive quality improvement throughout the organization.
- Collaborates with functional leads throughout the organization to integrate Behavioral Health aspects into the QI program and assure compliance with regulatory and accreditation requirements;
- Uses performance data from quality measurement and QI activities to improve the quality and safety of behavioral health clinical care and services provided to CareFirst members;
- Analyzes and evaluates the effectiveness of quality measurement and activities to identify and prioritize opportunities and gaps in care;
- Utilizes results from population based quality and satisfaction measurement to inform quality improvement interventions for the organization;
- Assures integration of behavioral health aspects within CareFirst policies, standard operating procedures, guidelines, programs and communications;
- Represents the behavioral health perspectives in the QI Committees to improve the quality and safety of behavioral health clinical care, safety and services; and
- Contributes behavioral health data and reports to the annual workplan and QI program evaluation.
2. Collects, analyzes and reports on mandated quality assessment
Through effective relationships throughout the organization, with trusted partners, clinical practices providing behavioral health care and with external regulators, the CareFirst Behavioral Health Quality Specialist assures compliance and drives improvement.
- Maintains knowledge of current and proposed accreditation standards, regulatory and healthcare quality, clinical practices, and quality measurement requirements and standards;
- Monitors compliance for all aspects of behavioral health accreditation and regulatory requirements and engages functional leaders to support quality efforts;
- Collaborates with functional leads to collect and analyze quality assessments for all aspects of behavioral health plan operations, clinical care, network adequacy, experience of care and safety;
- Oversees performance of Delegated functions/ Vendor activities;
- Supports and Oversees the collection of behavioral health HEDIS measurement;
- Analyzes processes, results and data trends to identify and prioritize opportunities;
- Utilizes lessons learned and industry best practices to drive improvement;
- Leads multidisciplinary workteam(s) in improvement activities for prioritized opportunities; and
- Coordinates, facilitates, documents and reports on all aspects of assigned project(s).
3. Leads behavioral health quality improvement activities
- Coordinates and leads QI related committees and/or work teams to collect and evaluate performance in the following areas for behavioral healthcare and services:
- complaints and appeals;
- Member Experience Survey;
- Transitions to other care;
- Continuity and coordination of care between medical and behavioral healthcare;
- Population health strategy and impact;
- Care Coordination and Total Care and Cost Improvement Programs;
- Access and Availability of behavioral health practitioners and providers;
- Utilization and Appeal programs and reports;
- Triage and referral of behavioral healthcare; Credentialing/Recredentialing and contracting; and
- Provider Satisfaction survey results.
- Conducts both quantitative and qualitative analysis to identify and prioritize opportunities for improvement;
- Analyzes processes, results and trends to recommend actions to implement QI activities that drive continual improvement;
- Measures the effectiveness of improvement actions; and
- Creates executive level and front-line reports and presentations.
- Any of the following: Bachelor’s Degree in health or behavioral health services or other advanced degree in behavioral healthcare related field with 3 years experience in a behavioral health environment. (Master’s Degree Preferred);
- Active involvement in successful submission of NCQA or other Health Plan or Managed Behavioral Health Organization Accreditation survey (preferred);
- Training or certification in Quality or Process Improvement Methods, preferred – or related training in an analytic field, including engineering, public health, or data science;
- Proven capacity to perform qualitative and quantitative data analyses and create innovative strategies and work with colleagues to address findings; and
- Ability to learn the technical aspects of collection and reporting of both administrative and clinical aspects of quality measures.
- Excellent verbal and written communications;
- Must be a critical thinker who uses sound judgment in the evaluation of performance throughout the organization;
- Must possess data fluency and be skilled in analyzing and presenting data;
- Broad knowledge of the behavioral healthcare industry including both clinical and operational aspects of Health Insurance Plan and products (preferred but not required); and
- Able to motivate people and influence change in a complex organization.
Department: Accreditation & Medical Programs
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 4/30/2018
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The physical demands described below are representative of those that must be met by an associate to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The employee must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted. Occasional driving is required.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship