Provider Network Quality Assurance Specialist

🕒 October 12

🌲 North Carolina – Remote

🌲 North Carolina – Remote

💵 $69.6k - $88.7k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔧 QA Engineer (Quality Assurance)

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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Alliance Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2012

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

Alliance Health is a regional health plan serving residents of several North Carolina counties by administering Medicaid and state-funded behavioral health and specialty services. It operates Tailored Plan coverage and Medicaid Direct options that integrate physical health, pharmacy, behavioral health, intellectual/developmental disability (I/DD), and traumatic brain injury (TBI) services, provides 24/7 behavioral health crisis support, member and provider portals, community trainings and outreach, and coordinates care through provider networks and governance committees.

📋 Description

• Monitor, audit, and improve the quality, accuracy, and compliance of provider network operations • Support provider data integrity, regulatory compliance, provider directory accuracy, and continuous process improvement • Conduct quality audits of provider network operations processes • Develop and maintain an audit schedule • Conduct research, analyze data, and recommend solutions for administrative, organizational, and operational problems • Maintain audit evidence and records for internal and external review readiness • Review provider directory accuracy and maintain documentation meeting DHB and NCQA requirements • Compare published information with source systems and coordinate outreach or research to resolve discrepancies • Prioritize corrections affecting member access, search results, or regulatory compliance • Perform root cause analysis, track corrective actions, and report results • Review provider data in Salesforce, Alliance Claims System, and enrollment and contracting systems • Verify contract terms, effective dates, network participation, locations, and reimbursement attributes • Identify and route missing, expired, inconsistent, duplicate, or incorrect information and track corrections through completion • Maintain audit criteria based on regulatory, accreditation, contractual, and internal policy requirements • Document compliance gaps, assess risk, and escalate significant findings • Support regulatory requirements, accreditation reviews, and internal compliance assessments • Partner with accountable teams to define corrective and preventive actions, owners, milestones, and due dates • Document all root cause analyses

🎯 Requirements

• Bachelor’s Degree in human services; Sociology, Psychology, Public Health, Statistics, Economics, Business Administration or related social science field from an accredited college/university • At least five (5) years of related experience providing quality assurance/improvement activities • Experience leading project teams focused on quality improvement projects • Excel proficiency required to analyze data and produce graphs and tables • Superior communication and writing skills • Strong organization and time management skills • Advanced knowledge of Microsoft Office applications, including Excel • Proficiency in MicroStrategy or other statistical or data modeling programs • Experience developing quality improvement plans for services to persons with complex physical health, behavioral health, and social determinant of health needs • Experience with project management processes • Ability to manage multiple projects • Ability to work with members, network providers, families, and government staff while considering cultural differences • Prior experience in Managed Care preferred

🏖️ Benefits

• Medical, Dental, Vision, Life, Long Term Disability • Generous retirement savings plan • Flexible work schedules including hybrid/remote options • Paid time off including vacation, sick leave, holiday, management leave • Dress flexibility

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