Provider Network Evaluator II – Clinical Quality

🔥 15 hours ago

🌲 North Carolina – Remote

🌲 North Carolina – Remote

💵 $61.4k - $78.3k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 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

• Conduct and lead Clinical Quality Reviews, Oversight Reviews, and Plan of Correction implementation reviews of contracted MH/IDD/SUD service providers • Lead, guide, support, and peer review team members’ work to ensure inter-rater reliability • Ensure contracted providers apply best practices, clinical guidelines, and regulatory requirements • Review paid claims data, clinical documentation, and personnel materials against applicable standards, policies, procedures, and regulations • Identify and substantiate clinical quality concerns, health and safety risks, service-planning gaps, and regulatory or administrative noncompliance • Distinguish isolated deficiencies from systemic patterns and assess potential impact on members • Provide technical assistance and monitor corrective actions through closure when a Plan of Correction is required • Interpret provider manuals, clinical coverage policies, scopes of work, ILOS, contracts, and governing standards • Report monitoring outcomes and potential impacts to the Provider Network Evaluator Supervisor and Director of Provider Network Evaluation • Apply advanced clinical expertise and treatment-modality knowledge to interpret provider information and document findings • Assist with standardized monitoring tools, guidelines, department policies, procedures, standards, and clinical quality standards • Develop monitoring policies and procedures for behavioral health, substance use, and I-DD services • Maintain provider database information gathered from monitoring activities • Develop quality indicators and provider profile elements in collaboration with Service Management • Maintain knowledge of services and supports available within the Alliance catchment area and North Carolina • Provide technical assistance to providers, stakeholders, and internal Alliance Health departments • Support Provider Network Evaluation teams and external Alliance units by sharing clinical information • Travel between Alliance offices, meet providers and stakeholders, attend meetings, events, and court hearings as required

🎯 Requirements

• Master’s degree from an accredited college or university in a Human Services field (such as Psychology, Social Work, etc.) • Minimum of three (3) years post master’s degree progressive experience in the field of mental health, developmental disabilities, or substance abuse • Must maintain a valid driver’s license and a good driving record • Must have full, current, and active NC license as an LCSW, LCAS, LCMHC, LPA, or LMFT • National Certified Investigator and Inspector Training (NCIT) is required; NCIT must be successfully completed within 6 months of hire and meet the 1-year employment requirements as a regulatory investigator/inspector • Working knowledge of federal and state statutes, rules, definitions, and regulations governing MHDDSAS services • Knowledge of evidence-based practices, levels of care, service planning, DSM criteria, and professional communication and writing • Knowledge of Clinical Coverage Policies, Records Management and Documentation Management • Knowledge of Mental Health, Developmental Disabilities, and Substance Abuse disability areas • Thorough clinical knowledge of treatment, habilitation, and support principles, concepts, and best practices • High level of diplomacy and discretion • Strong mediation skills • Excellent team building skills • Effective communication skills • Ability to identify and analyze administrative problems pertinent to the contract • Ability to make independent judgments, logical conclusions, recommendations, and decisions • Ability to determine appropriate action in emergency or stressful situations • Ability to maintain confidentiality of consumer data and provider business practices • Ability to review and analyze data to evaluate program effectiveness, progress, problems, and system performance • Ability to work effectively with internal and external parties

🏖️ 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