Quality Improvement Coordinator - Behavioral Health

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 stud 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 Coun