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RN Job In Seven Fields, Pennsylvania

Provider Quality Manager

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Company: JobTarget Profession/Specialty: RN Social WorkerPsychologist Location: Seven Fields, Pennsylvania 16046
Job Description

PA: Seven Fields

Job Family
Network Contracting/Provider Relations

Job Brief

We are currently seeking a dynamic Provider Quality Manager to join our team at our office in Cranberry Township, PA!


We are currently seeking a dynamic Provider Quality Manager to join our team at our office in Cranberry Township, PA! 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 data.

PQM performance is assessed not only on the ability to establish relationships and engage providers, but also by evidence of measurable improvements in clinical and quality outcomes for Beacon Members. Data trends to be measured for improvement include (but are not limited to):

  • 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

Building relationships with internal Beacon teams will be necessary to be successful in this role, in particular coordinating closely with clinical and quality departments, to ensure high quality care to members, and achievement of company HEDIS performance, as applicable to the regional market.

Position Responsibilities:

1. Implement regionally based strategies that meet clinical, quality, and network improvement goals through positive working relationships with providers, state agencies, advocacy groups and other market stakeholders.

2. Interface with a strategic subset of Beacon's network of behavioral health providers. Meetings with providers are face to face, telephonic and via Web-Ex. The Regional Provider Quality Lead in collaboration with other Regional and National leaders determines general parameters for type and frequency of meetings. Type and frequency of meetings for specific providers are determined on a case-by-case basis.

3. Liaison for Beacon clinical, quality, Provider Strategy, and network departments to ensure interdepartmental collaboration and coordination of goals and priorities.

4. Support 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.

5. Liaison between strategic providers and Beacon Operations, Claims and Provider Relations departments to support linkages for issue resolution, helping to improve provider experience and overall satisfaction with Beacon.

6. Ensure, and create as necessary and as applicable depending on the regional market, 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.

7. Partner with network providers and Beacon stakeholders to operationalize innovative programs and strategies to improve clinical and quality outcomes.

8. Analyze strategic provider reports pertaining to cost, utilization, and outcomes, and prepare this data to share with providers. Lead analysis of data sets that identify data outliers and opportunities for improvement for individual providers. Present data strategically, detailing patterns and trends in provider performance over time. Highlight key areas of focus, including interpretation of provider utilization data that show patterns. Ensure that data is kept meaningful to providers.

9. Share data to help educate strategic providers about Beacon's mission and vision, with a focus on driving high levels of value for Beacon members and delivering on performance on behalf of Beacon's clients.

10. Identify high-performing and innovative providers who may be interested in new programmatic or payment models. Gather information on program structure, function efficacy and outcomes to share with Beacon colleagues. Work with those providers to implement the new concepts. Communicate and collaborate with regional leadership to support provider activities consistent with Beacon's provider strategy and deliver progress to internal and external stakeholders. Collaborate 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. Help identify opportunities with regional and corporate leadership for expansion and development of innovative pilot programs, to include program development, implementation, launch, and efficacy and outcomes measurements. Provider innovations should reflect Beacon has thought leadership.

11. Contribute to the identification of best practices across the entire group of PQMs nationally and integrate high-quality program ideas/designs into the local market to drive high levels of value.

12. Provide consultation for clinically complex members.

13. Surface clinical and quality issues to Beacon's regional clinical and quality teams and participate in helping to address concerns.

14. Work with Beacon clinical teams to be knowledgeable regarding Beacon UM and care management programs and services, to be able to answer or appropriately triage provider questions.

15. Conduct medical record reviews annually or as needed with network providers across all service levels.

16. Assist with provider orientations and Beacon's network operations team will lead provider-training events in the region; trainings and orientations.

17. Closely collaborate with Beacon's network operations team to ensure a fluid bi-directional sharing of information.

18. Reliable transportation and ability to travel within local market on a regular basis is required.

19. Other duties and projects as assigned and specified by supervisor in line with Department and company needs.

Beacon anticipates the Provider Quality Manager will spend time each week in four main ways:

  • Strategic Provider outreach and meetings (2 - 3 days/week)
  • Analyze provider data to determine utilization and outcomes outliers, including root cause analysis for outliers and utilization patterns (1 day/week)
  • Developing strategy for specific provider engagement activities to be executed (1 day/week)
  • PowerPoint report generation to prepare for on-site provider outreach meetings (1/2 - 1 day/week)
  • Support linkage for Provider-specific problem resolution and navigation of Beacon by connecting providers to the appropriate Beacon staff (1/2- 1 day/week)


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Beacon Health Options is proud to be an Equal Opportunity and Affirmative Action Employer as well as a Drug Free and Tobacco Free Work Environment. EOE/AA/M/F/Veterans/Disabled

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