Provider Network Evaluator I-Clinical Quality (Full time Hybrid, Morrisville, North Carolina Based) (Biotech)
The Provider Network Evaluator I-Clinical Quality performs clinical quality reviews and plan of correction implementation reviews of service providers contracted with Alliance Health. Additionally, in limited situations, Provider Network Evaluator I may investigate instances of concerns to ensure individuals receive sufficient, safe, and effective services rendered by providers in the Alliance Health network.This is a hybrid work situation. The successful PNE I-Clinical Quantity candidate will work from home, but weekly travel will be required to conduct reviews.
This is a full-time hybrid position. You must live within a 60-mile radius of one of our Alliance offices. There will be occasions of on-site meetings and provider office clinical quality reviews with given notice from department head.
Responsibilities & Duties
Ensure Programs, Services, and Systems are Provided in Accordance with Alliance Health, Local, State and Federal Standards
- Acquire knowledge and understanding of Federal and State laws/rules/regulations, State Plan Documents, MCO Business Plan, Provider contracts, Provider Operations Manual, Records Management & Documentation Manual, Clinical Coverage Policies, Waivers, In Lieu of Services (ILOS), Scopes of Work (SOW), and so forth as applicable to ensure provider services comply with NC standards
- Conduct clinical quality reviews and plan of correction implementation reviews
- Interpret qualitative and quantitative information to document findings
- Cite and reference out of compliance items that do not meet requirements
- Report results and clinical documentation to Provider Network Evaluation Supervisor for review and approval
- In limited instances, Provider Network Evaluators may further investigate findings and results from a clinical quality review or plan of correction implementation review as deemed necessary and approved by leadership upon staffing
Assist in Department Policies, Procedures, and Standards
- Assist in the development of standards for service monitoring, quality improvement and evaluating the delivery of services to consumers and families, as well as quality indicators
- Assist in the development of monitoring policies and procedures
Provide Monitoring Information for Inclusion in Provider Database
- Work with Provider Network Team to maintain a provider database which will include information gathered from monitoring activities
- Assist in the development of Provider profile elements for the Provider database, in collaboration with the Service Management
Maintain Knowledge of Current Services and Supports Available
- Acquire and maintain knowledge of the current services and support available to consumers within North Carolina, including those within the MCO catchment area
- Provide technical assistance to providers, stakeholders and internal Alliance Health units as requested or as needed.
Travel
- Travel to meet with members, providers, stakeholders, attend court hearings, etc. is required
- Travel between Alliance offices, attending meetings on behalf of Alliance, participating in Alliance sponsored events, etc may be required
Minimum Requirements
Education & Experience
Bachelor's degree in human service field or social science field from an accredited College/University and three (3) years of post-degree experience in Mental Health and/or Substance Abuse fields. Preference will be given to those individuals with experience in healthcare compliance, quality assurance, provider monitoring, auditing, or investigations.
Candidate should possess working knowledge and experience regarding Medicaid and State funded Mental Health & Substance Use services available to members throughout NC & MCO Catchment area. Ideally, the Candidate will be able to demonstrate strong working knowledge including, but not limited to;
- DSM Diagnostic Criteria
- Ability to interpret written clinical summaries justifying recommended services
- I/DD services and service planning
- MH/SU Services including Levels of Care
- ASAM Criteria
- PCP Instruction Manual and Template
- Professional Communication and Writing
- Conflict Resolution Skills
The National Certified Investigator and Inspector Training (NCIT) is required. The PNE I candidate must be able to complete and pass the course within 6-months of hire and meet the 1-year employment requirement as a regulatory investigator/inspector.
Knowledge, Skills, & Abilities
- Working knowledge of federal and state statutes, rules, definitions and regulations that govern MHDDSAS services
- Knowledge of all disability areas including Mental Health, Developmental Disabilities and Substance Abuse
- Knowledge and understanding of the principles, concepts and Best Practices used in the treatment, habilitation and support of individuals with needs in any of the disability areas.
- High level of diplomacy and discretion
- Strong mediation skills
- Excellent team building skills
- Effective communication skills
- Ability to identify/analyze administrative problems pertinent to the contract
- Ability to make independent judgments, logical conclusions, recommendations and decisions
- Ability to determine the appropriate course of action in an emergency or stressful situation
- Ability to maintain confidentiality both of consumer data and provider business practices
- Ability to review and analyze data in an effort to evaluate program effectiveness, progress, problems and system performance
- Ability to work effectively with others internally and externally
Salary Range
$25 - $32.50/hourly
Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.
An excellent fringe benefit package accompanies the salary, which includes:
- Medical, Dental, Vision, Life, Long and Short 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
Education
Required- Bachelors or better in Human Services
Licenses & Certifications
Required- NCIT Specialized Cert
