The Sr. Behavioral Health Quality Reviewer conducts and coordinates quality review activities for behavioral health services. Provides clinical review, educational, consulting, and coordinating support to assigned areas. Coordinates with physicians, staff, and non-Kaiser providers and facilities regarding assessment of clinical care paths. In conjunction with physicians, monitors all clinical activities, makes recommendations, identifies cost-effective protocols, and develops guidelines for care.

• Performs concurrent review of ambulatory service records based on care standards and the level of care (LOC) needed (long term vs short term management plans):


• Review medication plan with primary diagnosis, coordination of medication plan between primary care and behavioral health practitioners.


• Review appropriate follow-up visits according to treatment plan, documentation and coordination of referral to internal and, external resources and transition plans in accordance with closure of the treatment plan.


• Review case notes are timely and reflect adequate time to reach goals outlined in the plan of care and the level of care need.


• Review the intake includes a thorough and accurate assessment for: suicide, homicide, abuse and appropriate legal reporting completion is documented.


• Review initial and follow-up appointments are appropriate to patients condition and treatment plan.


• Performs concurrent review of mental health assessments, diagnosis, treatment and crisis intervention services for members.


• Provides objective assessment of important aspects of patient care through ongoing chart review with pre-established criteria.


• Collaborates with treating physician, psychiatric and allied health professional team to assess each individual members treatment program.


• Collaborates with psychiatrists, allied health professionals, and other specialty care providers on psychological and neuropsychological plans of care.


• Reviews members treatment and progress in accord with state and NCQA regulations and in keeping with accepted community standards.


• Reports all occurrences which may lead to medical center liability and follows up as necessary.


• Facilitates interdisciplinary collaboration for implementation of evidence based guidelines, criteria and other clinical tools to reduce variation in clinical practice and to optimize clinical outcomes.


• Applies the appropriate performance improvement methodology to address improvement opportunity.


• Educates physicians and staff regarding regulatory reviews, i.e. the interpretation of regulatory requirements and the methods of compliance when preparing for a review or the interpretation of project goals.


• Supports the regional and medical centers continuous survey readiness program to maintain compliance with regulatory standards.


• Conducts quality management studies through data collection, data input and report development and analyzes, interprets and provides recommendation based on quality principles.


• Interprets regulations, health plan benefits, policies, and procedures for members, physicians, medical office staff, contract providers, and outside agencies.


• Develops and maintains relationships and effective communication with all levels of medical center physicians and staff in order to facilitate problem identification and resolution.


• Determines strategy for changing existing processes to meet regulatory requirements and translating external demands into program goals.


• Design and develop reports; track all work via tracking logs or other databases.