Behavioral Provider Quality Manager
Company: Anthem, Inc.
Posted on: June 8, 2021
SHIFT: Day Job
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
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
- 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
- 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
- Meets with providers face to face, telephonically and via
- 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
- 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
- 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
- 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
- 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
- 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
- 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
careers.antheminc.com. 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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