Chief Behavioral Health & Quality Officer

Location Address:

Summary:

Job Description:

* Ensure compliant operation of PHP's Children in State Custody program and manage reputational risk.
* Develop proactive monitoring processes for CISC and behavioral health contractual requirements.
* Build and maintain outreach strategies with key stakeholders, including providers and community organizations.
* Identify opportunities and risks related to behavioral health priorities and lead responsive initiatives.
* Oversee behavioral health vendor performance, ensuring integration of clinical services and contractual compliance.
* Lead implementation of behavioral health initiatives, including crisis continuum and clinical programs.
* Represent PHP in external engagements, including serving as primary contact for Kevin S. Settlement matters.
* Collaborate with VP Population Health & Quality and Chief Medical Officer to advance integrated care models.
* Develop and maintain a statewide behavioral health network.
* Work with product leads (Medicare, Commercial, Medicaid) to optimize behavioral health benefit design.
* Ensure compliance with state and federal regulations, contractual requirements, and NCQA accreditation standards.
* Oversee behavioral health reporting for all lines of business and maintain quality performance metrics.
* Promote behavioral health managed care concepts and cost-of-care strategies within the community.
* Develop policies, procedures, and workflows for all managed behavioral health functions.
* Provide leadership for staff development, training, and succession planning within the Behavioral Health Department.
* Own the health plan's risk adjustment strategy and results for behavioral health and CISC-related populations across Medicaid, Medicare Advantage, and Commercial/Exchange lines of business.
* Drive accurate, compliant diagnosis capture (e.g., HCCs) through provider documentation education, coding integrity programs, and collaboration with care management and quality teams.
* Establish a behavioral health coding integrity program that includes prospective, concurrent, and retrospective reviews; monitor for compliance with CMS/HHS and state regulations, and prevent any upcoding or inappropriate practices.
* Lead encounter data and risk submission operations (e.g., EDS/EDPS/RAPS as applicable) in partnership with IT and vendors; resolve submission errors and ensure high acceptance rates.
* Develop suspect-driven outreach and measurement-based care workflows to identify and confirm chronic behavioral health diagnoses and comorbidities.
* Partner with Healthcare Value Leader to integrate risk adjustment with Quality/HEDIS and Stars strategies to align interventions (e.g., follow-up after ED visit for mental illness, antidepressant medication management) with documentation and care outcomes.
* Create monthly RAF dashboards with drill-down by provider, region, product, and cohort (including CISC); track acceptance rates, coding accuracy, and documentation timeliness.
* Negotiate and govern vendor/partner contracts (including delegated BH vendors) with clear SLAs for risk adjustment, encounter data, analytics, and provider enablement.
* Lead provider engagement programs (training, toolkits, onsite/virtual consultations) to improve documentation quality for BH and pediatric complex cases; include measurement-based care and standardized screening tools.
* Monitor regulatory changes to risk adjustment models (CMS-HCC, HHS-HCC, state Medicaid models) and proactively update workflows, training, and system configurations.
* Coordinate cross-functional risk adjustment steering committee (Finance, Network, Quality, Clinical Ops, Compliance, IT) to ensure alignment and oversight.

Additional Job Description:

Minimum Qualifications:
* Bachelors degree required
* Minimum 8-10 years of experience in healthcare, BH, CISC, Medicaid roles.
* Expertise in health plan operations, regulatory programs, government relations, and vendor management.
* Demonstrated experience leading risk adjustment operations and analytics for one or more lines of business.
* Excellent leadership, communication, and internal and external stakeholder management skills.

Preferred Qualifications:
* Master's degree in Public Health, Health Administration, Social Work, Psychology, or related field.
* Certification(s): CRC (Certified Risk Adjustment Coder) or CPC, plus clinical coding and compliance training.
* Hands-on experience with encounter data submissions (e.g., EDS/EDPS/RAPS) and error remediation.
* Familiarity with NCQA accreditation standards and CMS/HHS risk adjustment regulations.
* Experience designing or managing value-based payment arrangements for behavioral health providers.

This position is open to remote applicants located within the United States, except residents in California, Illinois, North Dakota, New York, Ohio, Washington, and Wyoming.

Benefits
Benefits are effective day-one (for .45 FTE and above) and include:

• Competitive salaries
• Full medical, dental and vision insurance
• Flexible spending accounts (FSAs)
• Free wellness programs
• Paid time off (PTO)
• Retirement plans, including matching employer contributions
• Continuing education and career development opportunities
• Life insurance and short/long term disability programs

About Us
Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system ofnine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, it is the state's largest private employer with approximately 11,000 employees.

Presbyterian's story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, employees, board members, and other volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than 700,000 New Mexicans.

We are part of New Mexico's history-and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.

About New Mexico
New Mexico's unique blend of Spanish, Mexican and Native American influences contribute to a culturally rich lifestyle. Add in Albuquerque's International Balloon Fiesta, Los Alamos' nuclear scientists, Roswell's visitors from outer space, and Santa Fe's artists, and you get an eclectic mix of people, places and experiences that make this state great.

Cities in New Mexico are continually ranked among the nation's best places to work and live by Forbes magazine, Kiplinger's Personal Finance, and other corporate and government relocation managers like Worldwide ERC.

New Mexico offers endless recreational opportunities to explore, and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.