The Provider Network Evaluator II-Clinical Quality performs Clinical Quality Reviews (CQR), Oversight Reviews, and plan of correction implementation reviews of service providers contracted with Alliance Health. Additionally, in limited situations, Provider Network Evaluator II-CQ may investigate instances of concern to ensure individuals receive sufficient, safe, and effective services rendered by providers in the Alliance Health network.
This position is full-time remote. The selected candidate must reside in North Carolina and within 60-mile radius of any of Alliance Office. Some travel for onsite meetings, travel to conducting reviews, and monitoring may be required; up to two days per week.
Responsibilities and Duties
Clinical Quality Reviews of MH/IDD/SUD Providers in the Alliance Health Network
- 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 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
- Assist in the development of monitoring policies and procedures pertaining to behavioral health and I-DD services
Provide Monitoring Information for Inclusion in Provider Database
- 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
Maintain Knowledge of Current Services and Supports Available
- 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
- 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
Minimum Requirements
Master’s degree from an accredited college or university in a Human Services field (such as Psychology, Social Work, etc.) and 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. The licensed professional will be expected to provide clinical guidance and interpretation in support of the CQR process. 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.
Knowledge, Skills, and 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
- 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
Employment for this position is contingent upon a satisfactory background and MVR (Motor Vehicle Registration) check, which will be performed after acceptance of an offer of employment and prior to the employee's start date.
Salary Range
$60,234 - $76,799/Annually
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