External Clinical Quality Analyst I (Full-time Remote, North Carolina Based)

Alliance Health; Morrisville (NC); À distance; USD 41 000 - 52 000; Plein temps

Résumé du poste

Alliance Health in North Carolina is seeking an External Clinical Quality Analyst I to manage quality reviews for provider-led care management programs. The role is fully remote but requires residency in North Carolina and some travel to the Home office may be needed.

The role involves auditing policy and procedures, analyzing data to identify trends, and coordinating staff training to meet NCQA and regulatory guidelines. Strong analytical and communication skills are essential.

Qualifications

• Bachelor’s degree in a field related to health services with four years of care management experience.
• Bachelor’s degree in Human Services with three years of care management experience in relevant populations.
• Three years of experience conducting provider monitoring/investigations or program evaluation activities.
• Experience developing or reviewing care plans, comprehensive assessments, care management interventions, and service engagement activities.
• Knowledge of Medicaid Managed Care and integrated care concepts.

Responsabilités

• Analyze Care Management documentation and activities to ensure compliance with NC DHHS Tailored Care Management guidelines.
• Audit provider-led Care Management policy, staffing, training, and clinical documentation for alignment with guidelines and regulatory requirements.
• Analyze program data to identify trends and develop corrective action plans as needed.
• Provide written feedback to leadership on quality concerns, risks, and trends.
• Evaluate staff knowledge gaps and coordinate training with relevant teams.

Connaissances

Analysis

Communication

Diplomacy

Problem Solving

Formation

Bachelors in Human Services

Bachelors in General Studies

Bachelor’s degree in non-Human Services field

Outils

Microsoft Excel

PowerPoint

SPSS

Survey Monkey

Word

Description du poste

The External Clinical Quality Analyst I manages the quality review process for provider-led care management programs. Incumbents conduct quality reviews and audits of provider-led care management programs and processes for quality assurance purposes and to support the effective functioning of provider-led care management.

This position is full-time remote. Selected candidate must reside in North Carolina. Some travel for onsite meetings to the Home office may be required.

Responsibilities & Duties

Analyze Care Management Documentation and Activities to Ensure Compliance

• Review the quality of provider-led Care Management programs by completing administrative reviews is coupled with detailed clinical case reviews for alignment with all requirements identified in the NC DHHS Tailored Care Management Provider Manual
• Audit provider-led Care Management policy and procedures, staffing, training, and provision of all Care Management activities including clinical documentation to ensure alignment with program descriptions, workflows, evidence based clinical guidelines, NCQA guidelines, CMS guidelines, and regulatory guidelines (when applicable)
• Analyze program data to identify trends and to develop and implement corrective action plans as appropriate
• Interpret qualitative and quantitative information to appropriately document findings and ensure contractual requirements are met
• Identify system and/or operational issues hindering the attainment of quality performance standards as defined by NCQA standards, applicable state and Federal laws and regulations

Analyze Data and Report on Findings

• Provide written feedback to the Senior Director of Network Evaluation, Practice Transformation Team, and Compliance concerning quality concerns pertaining to program performance, and compliance risks/trends

Evaluate Knowledge Gaps of Staff and Coordinate Training

• Evaluate knowledge gaps of the provider-led Care Management staff and collaborate with Provider Network, Practice Transformation and Care Management Leadership to coordinate learning and training opportunities for provider-led Care Management entities

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

Education & Experience

Bachelor’s degree in a non-Human Services field and four (4) years of experience with providing care management to individuals in the following populations: Traumatic Brain Injuries (TBI), Intellectual/Developmental Disabilities (I/DD), Mental Health/Substance Use Disorders (MH/SUD), Severe Mental Illness (SMI), or Physical Health (PH)

OR

Bachelor’s degree in a Human Services field and three (3) years of experience with providing care management to individuals in the following populations: Traumatic Brain Injuries (TBI), Intellectual/Developmental Disabilities (I/DD), Mental Health/Substance Use Disorders (MH/SUD), Severe Mental Illness (SMI), or Physical Health (PH)

OR

Bachelor’s degree in a Human Services field and three (3) years experience conducting provider monitoring/investigations or program evaluation activities.

Required experience

Experience developing or reviewing Care plans, comprehensive assessments, care management interventions, and service engagement activities

Medicaid Managed Care

Integrated care (behavioral and physical health) or

Program/services monitoring, program evaluation

Preferred Experience

Auditing Clinical documentation

Preferred Certification

Certified Care Manager (CCM)

Knowledge, Skills, & Abilities

• Knowledge of North Carolina State and Federal rules and requirements related to the service continuum in North Carolina
• Knowledge of Tailored Plan, Integrated Care and Care Management processes and regulatory requirements
• Knowledge of best and promising practices for behavioral & physical health and/or intellectual/developmental disabilities
• Microsoft Excel, Word, PowerPoint, SPSS, and Survey Monkey (or other online survey tool)
• Strong clinical skills
• Problem solving skills
• Interpersonal Skills
• Strong Analytical skills
• Problem solving and conflict resolution skills
• Strong diplomacy skills and discretion
• Highly effective communication skills
• Ability to negotiate and resolve issues with minimal assistance

Salary Range

$29.54 - $37.66/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 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

Preferred

• Bachelors or better in Human Services
• Bachelors or better in General Studies

Skills

Required

• Analysis
• Communication
• Diplomacy
• Microsoft Office
• Problem Solving

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.