External Clinical Quality Analyst I

Job not on LinkedIn

🔥 2 hours ago

🌲 North Carolina – Remote

🌲 North Carolina – Remote

💵 $29 - $37 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

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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

• Manage the quality review process for provider-led care management programs • Conduct administrative and detailed clinical case reviews for compliance with the NC DHHS Tailored Care Management Provider Manual • Audit provider-led care management policies, procedures, staffing, training, activities, and clinical documentation • Assess alignment with program descriptions, workflows, evidence-based clinical guidelines, NCQA guidelines, CMS guidelines, and regulatory guidelines • Analyze program data, identify trends, and develop and implement corrective action plans • Interpret qualitative and quantitative information, document findings, and ensure contractual requirements are met • Identify system and operational issues affecting quality performance standards • Provide written feedback to the Senior Director of Network Evaluation, Practice Transformation Team, and Compliance regarding quality concerns and compliance risks/trends • Evaluate provider-led care management staff knowledge gaps and coordinate training opportunities with relevant leadership teams • Travel between Alliance offices and attend meetings, events, meetings with members, providers, stakeholders, and court hearings as required

🎯 Requirements

• Bachelor’s degree in a non-Human Services field and four (4) years of experience providing care management to individuals with TBI, I/DD, MH/SUD, SMI, or PH; OR • Bachelor’s degree in a Human Services field and three (3) years of experience providing care management to individuals with TBI, I/DD, MH/SUD, SMI, or PH; OR • Bachelor’s degree in a Human Services field and three (3) years of experience conducting provider monitoring/investigations or program evaluation activities • Experience developing or reviewing care plans, comprehensive assessments, care management interventions, and service engagement activities • Experience with Medicaid Managed Care • Experience with integrated care (behavioral and physical health) or program/services monitoring and evaluation • Knowledge of North Carolina state and federal rules and requirements related to the service continuum • Knowledge of Tailored Plan, Integrated Care, and Care Management processes and regulatory requirements • Knowledge of best and promising practices for behavioral and physical health and/or intellectual/developmental disabilities • Proficiency with Microsoft Excel, Word, PowerPoint, SPSS, and Survey Monkey or another online survey tool • Strong clinical, analytical, problem-solving, conflict-resolution, interpersonal, diplomacy, discretion, communication, negotiation, and issue-resolution skills • Preferred: auditing clinical documentation • Preferred certification: Certified Care Manager (CCM)

🏖️ 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