BH Clinical Quality Management Analyst Sr. CPHQ/HCQM

Anticipated End Date:

2025-08-08

Position Title:

BH Clinical Quality Management Analyst Sr. CPHQ/HCQM

Job Description:

Clinical Quality Management Analyst Sr. Behavioral Health

Location: 111 Wood Ave. S, Iselin, NJ 08830

Clinical Quality Management Analyst Sr. Behavioral Health

Location: 111 Wood Ave. S, Iselin, NJ 08830

This role requires associates to be in-office 1-2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The Behavioral Health Clinical Quality Analyst Sr. is responsible for developing and conducting more complex behavioral health quality studies by analyzing data and patterns according to department criteria, external review organizations, and other regulatory agencies.

How You Will Make an Impact:

Primary duties may include, but are not limited to:

• Conducts behavioral health provider on-site audits researching behavioral health provider clinical quality issues. Ensuring the contractor or its behavioral health subcontractor comply with quality management requirements.
• Implementation of quality measures of network adequacy. Implementation of processes designed to improve access to care for special needs populations including, but not limited to, physically handicapped individuals, individuals with co-occurring conditions, victims of sexual abuse, deaf or blind individuals, pregnant women, and individuals with developmental delays.
• Resolving, tracking, and trending quality of care complaints.
• Prepares corrective action plans in response to oversight body's request.
• Conducts behavioral health audits of QM processes and files. Ensuring the network is capable of providing services to a culturally and ethnically diverse population with attention to disparities in access or outcomes experienced by traditionally marginalized populations
• Writes policies and procedures.
• Assists with development of behavioral health provider manuals, audit tools, and guidelines.
• Coordinates collection and organization of information and documents in preparation for regulatory audits.
• Participates in development and design of audit tools, policies and procedures, and behavioral health provider manuals.
• Completes quarterly Quality Management (QM) coalition reports for submission to regulatory bodies.
• Ensuring that systems and procedures exist that assess provider satisfaction. Assessment shall include provider experiences with claims processing, prior authorization, utilization management, and provider complaint resolution,
• Conducts new hire orientation and on-the-job training sessions.
• Travels to worksite and other locations as necessary.  

Minimum Requirements:

• Requires a BA/BS in a behavioral health related field and a minimum of 3 years behavioral health clinical and managed care or clinical quality improvement experience; or any combination of education and experience which would provide an equivalent background.
• Certified Professional in Healthcare Quality (CPHQ) by the National Association for Healthcare Quality, or be Certified in Healthcare Quality and Management (HCQM) by the American Board of Quality Assurance and Utilization Review Physicians or similar certifications may be required according to state location; or obtain it within 90 days of date of hire.

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Preferred Skills, Capabilities & Experiences:

• 3 years of experience in Quality Management/Quality Improvement highly preferred.
• MS/MA degree preferred.
• Experience working with MCO or the State of New Jersey.
• Experience working with BH providers, experience analyzing data, reporting writing, and interpretation of policies and procedures.

For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $84,088 to $105,110

Location:  New Jersey

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific posit