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Behavioral Provider Quality Manager

Company: Anthem, Inc.
Location: Vallejo
Posted on: June 8, 2021

Job Description:


SHIFT: Day Job

SCHEDULE: Full-time

Your Talent. Our Vision. At Anthem, Inc., it's a powerful combination, and the foundation upon which we're creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.

For more than 30 years, Beacon Health Options has changed the way people live with behavioral health conditions. Today, we are the undisputed leader in behavioral health management, serving 37 million people across all 50 states. At Beacon, our mission is to help people live their lives to the fullest potential. Beacon offers superior clinical mental health and substance use disorder management, a comprehensive employee assistance program, work/life support, specialty programs for autism and depression, and insightful analytics to improve the delivery of care.

Location: Work from home - located in NorCal (SF, East Bay, North Bay, Sonoma, Shasta County, Solano County)

Responsible for leading Behavioral Health (BH) provider engagement, with a focus on leveraging the data available to providers and helping to improve the value delivered to Beacon members. Drives BH provider performance improvement year over year through education and data. Provider Quality Managers (PQM) are strategically oriented professionals who help lead the next generation of provider engagement, with a focus on leveraging the data available to providers, helping to improve the value delivered to Beacon members. PQMs achieve this by building highly collaborative strategic partnerships and bringing an analytic mindset to discussions with providers. PQMs drive provider performance improvement year-over-year through education and data.

PQM performance is assessed not only on the ability to establish relationships and engage providers, but by evidence of measurable improvements in clinical and quality outcomes for Beacon Members. Data trends to be measured for improvement include (but are not limited to):

  • FUH, IET and other HEDIS outcomes
  • Cost metrics
  • Trends in length of stay
  • Readmission Rates
  • Community Tenure
  • Access to medically necessary care
  • Successful transitions of care
  • Quality outcomes
  • Other utilization patterns and trends

This role is responsible for a local market. Primary duties may include, but are not limited to:

  • Establishes relationships and engages with BH providers and ensures measurable improvements in clinical and quality outcomes for members.
  • Builds relationships with internal clinical and quality departments to ensure high quality care to members and achievement of company HEDIS performance.
  • Implements strategies that meet clinical, quality, and network improvement goals through positive working relationships with providers, state agencies, advocacy groups and other market stakeholders.
  • Meets with providers face to face, telephonically and via Web-Ex.
  • Acts as a liaison between strategic providers and Beacon clinical, quality, provider strategy, network departments, operations, claims and provider relations to ensure interdepartmental collaboration and coordination of goals and priorities and to support linkages for issue resolution, helping to improve provider experience and overall satisfaction with Beacon.
  • Supports regional and corporate initiatives regarding Alternative Payment Models (APM), including Value Based Payment (VBP), clinical innovation, and thought leadership transforming provider relationships from transactional interactions to collaborative aggregate data assessment.
  • Creates and maintains linkages between providers of all levels of care, as well as other community -based services and resources to improve transitions of care and continuity of services.
  • Partners with network providers and Beacon stakeholders to operationalize innovative programs and strategies to improve clinical and quality outcomes.
  • Analyzes provider reports pertaining to cost, utilization, and outcomes, and presents the data to providers and highlights trends.
  • Identifies data outliers and opportunities for improvement for individual providers. Identifies high-performing and innovative providers who may be interested in new programmatic or payment models.
  • Collaborates with regional leadership and network teams to identify providers who are best suited for APMs, preferred provider networks, and/or other aggregate data management programs.
  • Participates in the identification of opportunities for expansion and development of innovative pilot programs, to include program development, implementation, launch, and efficacy and outcomes measurements.
  • Contributes to the identification of best practices and integrates high-quality program ideas/designs into the local market to drive high levels of value. Provides consultation to providers for clinically complex members as applicable.
  • Surfaces clinical and quality issues to regional clinical and quality teams and participates in helping to address concerns.
  • Conducts medical record reviews annually or as needed with network providers across all service levels.
  • Assists with provider orientations and provider training events in the region, when applicable


  • Requires Master's degree or above in Behavioral Health field.
  • 10 years of progressively responsible professional experience in healthcare, with at least 5 of those years in an behavioral health setting, either provider or payer; or any combination of education and experience, which would provide an equivalent background.
  • Managed care experience preferred.
  • Requires current unrestricted RN, LCSW, LMFT, LCPC or Clinical Psychologist license in CA

Anthem, Inc. is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.

Keywords: Anthem, Inc., Vallejo , Behavioral Provider Quality Manager, Other , Vallejo, California

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