Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

A Brief Overview
The QM BH Consultant develops and implements data-driven strategies/interventions that ensure the delivery of time sensitive behavioral health benefits and services for members. The QM BH Consultant directs coordination of care between the member, clinical care team, and providers and takes part in the analysis and reporting of member data to monitor outreach effectiveness. The QM BH Consultant conducts targeted member/provider education and outreach initiatives and supports the development of HEDIS interventions and initiatives within the Quality Management Team. The QM BH Consultant reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with HEDIS, regulatory, and accreditation requirements for member and/or provider issues. This position independently coordinates the clinical resolution for members with behavioral health needs with internal/external clinician support as required.

• Collaborates with various health management team members to develop specific interventions that will improve members health status, members adherence to care plan, and compliance with coordinated services.
• Reviews documentation and evaluates potential quality of care/gap in care issues based on clinical policies and benefit determinations.
• Conducts outbound telephone calls to members regarding service compliance with behavioral health providers.
• Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.
• Offers consultant services and education to network providers to improve adherence to HEDIS requirements.
• Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand
• Data gathering requires navigation through multiple system applications.
• Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.
• Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information for Quality Management audit purposes or coordination of member services.
• Local travel to network provider offices may be required
• Pro-actively and consistently applies the regulatory and accreditation standards to assure that activities are reviewed and processed within guidelines.
• Condenses complex information into a clear and precise clinical picture while working independently
• Commands a comprehensive knowledge of complex delegation arrangements, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the review of the clinical documentation/information.
• Reports audit or clinical findings to appropriate staff or others in order to ensure appropriate outcome and/or follow-up for improvement as indicated.

• Licensed Behavioral Health Clinician in Ohio i.e. LISW, LPCC, LSW
• 3+ years' experience in practice management in a healthcare setting
• 3+ years' experience in healthcare with a focus on HEDIS and Quality with experience facilitating and leading meetings with provider offices and proven track record of improving performance with your market
• An ability to travel less than 10% across Ohio for in-person provider support. Valid driver's license in good standing and access to a reliable vehicle required with insurance

• Experience working in a behavioral health, residential, or psychiatric setting
• Proficient in Microsoft Office tools such as Excel, Teams, Outlook, PowerPoint, and Word
• Articulate and professional communication skills, both verbally and written
• Knowledge of HEDIS and Pay for Performance metrics, and common billing practices
• Strong analytical skills regarding HEDIS metrics and quality reporting
• Demonstrated understanding of Medicaid industry standards and NCQA requirements
• Ability to manage relationships with an emphasis on internal and external mid-level relationships
• Ability to work across all levels of the organization, including working with executive audiences, vendors, and government as a customer
• Demonstrated ability to project manage and implement strategies to improve performance
• Demonstrated experience in leading significant cross-functional work that includes business owners, executive leadership, and peers across the organization

• Minimum Bachelor's degree in the healthcare field, social work, or the behavioral health field required