A day in the life of a Carelon Behavioral Health provider quality manager

The role of a provider quality manager (PQM)

A provider quality manager (PQM) collaborates with providers to improve the quality of care that members receive. The PQM reviews data with providers, working together to identify opportunities for improvement. By measuring the outcomes and the effects of various factors, PQMs can pinpoint challenges that providers experience when delivering care. PQMs can then recommend processes to improve the overall quality of care.¹

 

How a Carelon Behavioral Health PQM works with providers

“I work with providers who specialize in applied behavioral analysis (ABA), primarily treating members diagnosed with autism spectrum disorder (ASD),” says Danielle Manska, MA, BCBA, Provider Quality Manager, Carelon Behavioral Health. Manska supports ABA providers throughout California. “ABA is effective in treating developmental disorders in addition to ASD, so I work with providers in additional specialties as needed.”

ABA therapy utilizes positive reinforcement to teach individuals social skills, communication abilities, learning and academic skills, and self-care habits. The goal of ABA is to increase individuals’ behaviors that are helpful and decrease behaviors that are harmful or that affect learning.²

“I collaborate with providers both virtually and in person, giving them feedback and recommending strategies to eliminate barriers that may affect the quality of care," says Manska. "I help an average of 30 providers per quarter. I meet with some monthly. I even meet with one weekly to support them on a grant-based program increasing member and community access to trauma-informed care.”

 

What kinds of challenges do you assist providers with?

Manska works with strategic providers who treat a significant number of Carelon members. While she primarily works with providers delivering care to children and youth, she also works with providers who treat adults. “I present quality improvement metrics to providers. I also ensure that utilization rates across services meet industry best practices," she says.

Providing feedback is a large part of Manska’s role, “I review with providers metrics and benchmarks populated through claims data. I present the results and go over industry recommendations and best practices. Examples include decreasing wait times that members experience when seeking an initial assessment, sorting billing codes, and increasing member access.”

Manska offers strategies to help providers eliminate barriers to treatment, sometimes involving the referral or clinical teams. “I also look at the quantity and quality of the direct hours that the provider works with the member. I need to confirm that providers put in a minimum of 10% or more direct hours per member, as the range we target per member is 10% to 20%," she says.

Reviewing parent involvement with the provider is another vital part of Manska’s role. “I look at parent training utilization. We want to include the parent in the member’s treatment as much as possible, especially for children and youth. How much is the provider offering parent training? We generally target and recommend at least two hours of parent education per month, per member.”

She also brings in Provider Relations when appropriate, offering feedback on quality of care. She is part of two work groups. “I meet virtually with two different teams weekly. Even though the meetings are virtual, they are still very tied in and collaborative.”

 

How did you get into the field?

“I started my career as a provider," Manska says. "I had been working in the ABA field for 15 years, and I was ready for a new challenge. I’ve always been fascinated by data, I wanted to help improve processes, and I was hoping to utilize my PhD-level studies. So, I found this opportunity with Carelon and was so excited. I’m still in the field and making an impact, consulting with providers, and working with them on improving their quality of care.”

Manska emphasizes the uniqueness of her position, having the opportunity to work with so many providers in California on quality improvement and systemic-level change. “I’ve seen so much improvement in provider utilization and quality of care.”

 

Can you share a case in which you made the most difference?

“I worked with Children’s Developmental Milestones, a Carelon Behavioral Health Provider of the Month that had achieved incredible progress in their metrics. I had helped the provider — that is part of our preferred provider network — to exceed their metrics," says Manska. "I They have maintained their status for the last two years. They stand out because their treatment plans are up to par, and they implement suggestions immediately. Children’s Developmental Milestones has increased member access to two additional health plans, and they are increasing member access across Carelon.”

 

What inspires you the most about your job?

Manska emphasizes the two most motivating aspects of her role: “For one, my team is diverse and highly skilled. My coworkers include various PQMs from other departments, and my manager continually inspires me, for which I am very grateful."

“Secondly, the clinical part is hugely rewarding," Manska adds. "Being part of something so big and having the ability to make changes and affect progress is so gratifying. My providers regularly tell me how wonderful it is that they have someone to talk to who works for a managed care plan. I’ve been in their position and know the challenges, when trying to get ahold of someone. They love that I’m so readily available. And that’s what continues to motivate me.”