Alliance Health · 1 day ago
Provider Network Evaluator II-Clinical Quality Review
Raleigh, NC
Full-time
Onsite
Mid Level
3+ years expAlliance Health is seeking a Provider Network Evaluator II-Clinical Quality Review to perform Clinical Quality Reviews and Oversight Reviews of service providers. This role involves assessing compliance with best practice standards and providing technical assistance to ensure safe and effective services in the Alliance Health network.
Health Care
Hiring Manager
Theresa Wells
Responsibilities
Conduct clinical quality reviews and Oversight Reviews as required and assigned
Review paid claims data, clinical documentation and personnel materials against best practice standards, policies and procedures, clinical coverage policies, administrative code, regulatory guidance among other resources
Identify out of compliance findings, clinical concerns and other findings and provide technical assistant and/or oversight of the plan of correction (POC) process for those network providers with systemic findings
Review Provider Operations Manual, Scopes of Work (SOW), In Lieu of Services (ILOS) and Provider contracts for additional requirements in the delivery of services and care
Report monitoring outcomes and the potential impact on consumers to the Provider Network Evaluator Supervisor and the Director of Provider Network
Use of clinical expertise, knowledge of best practice and treatment modalities to effectively interpret qualitative and quantitative provider information to appropriately support and document findings
Assist in the development of standards for service monitoring, quality improvement and evaluating the delivery of services to consumers and families
Assist in the development of monitoring policies and procedures pertaining to behavioral health and I-DD services
Work with Provider Network Evaluation Teams to maintain a provider database that includes information gathered from monitoring activities
Assist in the development of quality indicators and Provider profile elements for the Provider database, in collaboration with Service Management
Acquire and maintain knowledge of the current services and supports available within the Alliance catchment area and available to consumers within North Carolina
Provide technical assistance to providers, stakeholders and internal Alliance Health departments as requested and needed
Support PNE CQR teams by sharing clinical information and knowledge as needed in a formal and ad hoc manner
Travel between Alliance offices, attending meetings on behalf of Alliance, participating in Alliance sponsored events, etc. may be required
Travel to meet with members, providers, stakeholders, attend court hearings etc. is required
Qualification
Required
Master's degree from an accredited college or university in a Human Services field (such as Psychology, Social Work, etc.)
A 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
Knowledge of evidence-based practices, levels of care, service planning, DSM criteria and professional communication and writing skills are necessary
The 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 that govern MHDDSAS services
Knowledge of all disability areas including Mental Health, Developmental Disabilities and Substance Abuse
Thorough Clinical 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 to evaluate program effectiveness, progress, problems and system performance
Ability to work effectively with others internally and externally
Company
Alliance Health
Alliance Health is the managed care organization for publicly funded behavioral healthcare services.
Founded in 2012Fayetteville, North Carolina, USA
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Kelly Goodfellow
Executive Vice President, Chief Financial Officer
Recent News
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