This is a quality and operational expert responsible for clinical performance reviews of staff effectively completing outreach, engagement and care management (CM) activities across Medicaid, Medicare, and Whole Health businesses. The QA and Performance Auditor collects and synthesizes information from activity records, recorded calls, and other engagement /CM data to support KPI tracking and quality across the Center of Operational Excellence (CoOE) and supports coaching and performance improvement of all clinical front-line staff. The QA and Performance Auditor reports directly to the Clinical Operations Quality and Performance Manager and supports functions across all member market clinical operations. This role also collaborates in a matrix environment with the CoOE to ensure quality and performance monitoring supports the appropriate clinical Key Performance Indicators (KPI) in accordance with industry leading practices, client contracts, accreditation bodies, and Magellan's goal of delivering on the Quadruple Aim. The goal of the Quadruple Aim is to enhance patient experience, improve population health, reduce costs, and improve the work life of health care providers, including clinicians and staff.
Operational Responsibilities

• Conduct audits on staff performance and track and monitor adherence to quality of operational activities by reviewing records, recorded calls and noting variances from department processes or protocols.


• Monitor, track and identify trends in individual and group performance across engagement and CM.


• Identify areas of continuous operational performance improvement across the team and support the QA Coordinator in implementing improvements.


• Participate in training of new staff on CoOE processes, protocols, quality data collection, KPIs, targets and departmental resources.


• Monitor ongoing communications and performance to Care Management program standards by role; determine need for potential re-training or Performance Improvement Plan (PIP) and communicate directly to supervisors/managers regarding staff needs.


• Build team member expertise through direct feedback and real-time coaching, providing clinical, procedural and interpretational assistance.


• Support goal setting and regular performance reviews of engagement and CM staff.


• Work with CoOE leadership to develop individualized quality performance improvement plans.


• Perform root cause analysis of issues relating to missed KPI trends, performance quality, or other common escalated clinical issues, and support identification of opportunities for improvement and resolution of root cause issues.


• Oversight of clinical specific responsibilities in customer delegation, accreditation, regulatory, CMS audits; participation and demonstration of clinical compliance areas during the external audit.

• Engage with staff and leadership in a manner that supports a culture appropriate to support Magellan's mission, vision, and values.


• Promote, act, and collaborate as a unified team to drive system alignment towards Magellan's vision.


• Maintain a working knowledge of applicable Accreditation, Federal, State, and local laws and regulations, Magellan Compliance standards, Standards of Conduct, as well as other policies to understand potential impact on performance management and quality assurance practices and measurement in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.


• Establish a clear, reputable, personal brand, and serve to inspire colleagues.


• Encourage teamwork and teambuilding.

Responsibilities
5+ years of experience in technology, quality assurance, operations support, managed care experience and or equivalent role.
3+ years of behavioral health experience.
Effective written and verbal communication skills.
Proven track record of executing or overseeing verbal engagement or care management functions based on best practice protocols and processes.
Knowledge of Medicaid, Medicare, and Commercial behavioral health managed care programs and regulations.
Understanding of health plan functions related to care and quality management, affordability, as well as HEDIS/STARs and NCQA requirements.
Experience with and understanding of behavioral health conditions and associated challenges.
Familiarity with CMS regulations and standards.

General Job Information

Title
Quality Assurance and Performance Auditor

Grade
25

Work Experience - Required
Operations, Quality

Work Experience - Preferred

Education - Required
Master's - Clinical Psychology, Master's - Nursing, Master's - Social Work

Education - Preferred

License and Certifications - Required
LCSW - Licensed Clinical Social Worker - Care Mgmt, LPC - Licensed Professional Counselor - Care Mgmt, LSW - Licensed Social Worker - Care Mgmt, RN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt

License and Certifications - Preferred
LSSBB - Lean Six Sigma Black Belt Certification - Enterprise

Salary Range

Salary Minimum:
$64,285
Salary Maximum:
$102,855

This information reflects the anticipated base salary range for this position based on current national data. Minimums and maximums may vary based on location. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law.

This position may be eligible for short-term incentives as well as a comprehensive benefits package. Magellan offers a broad range of health, life, voluntary and other benefits and perks that enhance your physical, mental, emotional and financial wellbeing.

Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.
Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.