Provider Network Evaluator I, Targeted Monitoring

🔥 0 minutes ago

🌲 North Carolina – Remote

🌲 North Carolina – Remote

💵 $29 - $37 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

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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

• Conduct targeted and focused monitoring of quality of care, health and safety, incident reports, service delivery, Medicaid contract and state funding compliance, provider operations, and other concerns • Develop monitoring plans based on referrals, internal documents, allegations, and identified concerns • Create review tools specific to each targeted or focused monitoring activity • Request, collect, document, inventory, and store clinical records, medical records, personnel records, policies, procedures, quality management plans, and other evidence • Conduct interviews with internal employees, provider employees, former employees, service recipients, and other individuals • Identify noncompliance findings, health and safety issues, overpayments, and irregularities; determine whether allegations are substantiated • Record and track monitoring and audit activities from referral through final disposition • Document allegations, communications, investigative activities, reviews, and findings in detailed audit/investigation reports • Lead reviews or collaborate with the PNE Targeted Team • Research clinical coverage policies, administrative codes, bulletins, scopes of work, service manuals, provider operations manuals, and federal/state laws • Present review findings and disposition recommendations to leadership, compliance committees, and general counsel when necessary • Provide case status updates and present oral or written reports to stakeholders • Interpret and convey highly technical information • Review claims, authorizations, credentialing/enrollment, Jiva, grievances, prior audits/investigations, incident reports, and policies/procedures • Utilize MicroStrategy reports during pre-investigation and investigation processes • Review claims data and authorizations to identify irregularities and concerns • Prepare improper payment charts and statements of deficiency; provide provider feedback and technical assistance • Follow up on corrective actions and participate in provider appeals, reconsiderations, and court hearings • Recommend revisions to Alliance Health procedures and policies • Consult Corporate Compliance and refer suspected fraud, waste, and abuse to Special Investigations • Perform other duties assigned by the Supervisor

🎯 Requirements

• Bachelor’s degree in human services or social sciences from an accredited College/University • Five (5) years of post-degree experience in healthcare compliance, provider monitoring, policy development, auditing, investigations, accreditation, or equivalent combination of related training and experience • NCIT preferred but not required; must be successfully completed within 6 months of hire • Health care industry and/or Medicare/Medicaid/Behavioral Health knowledge preferred • Knowledge and proficiency in claims adjudication standards and procedures • Knowledge of state and federal Medicaid laws, regulations, policies, rules, guidelines, service limitations, and Medicaid programs • Knowledge of Alliance Health service benefit plans and network providers • General understanding of MCO functions involving prior authorization, utilization reviews, grievance management, provider credentialing, and monitoring • Proficiency using Microsoft Office products, including Word, Excel, and Outlook • Strong verbal and written communication skills • Ability to write clear, accurate, and concise rationale supporting findings • Analytical, deductive, logical, and sequential thinking skills • Ability to identify resources, gather evidence, analyze raw data, and generate reports • Ability to interpret contractual agreements, business-oriented statistics, medical/administrative services, and records • High degree of integrity, discretion, and confidentiality • Ability to manage time, prioritize work, and use problem-solving approaches • Knowledge of investigative methods and procedures

🏖️ 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