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

Alliance Health; Morrisville (NC); Remote; USD 70,000 - 89,000; Full time

Benefits offered by this job

Medical, Dental & Vision

Generous retirement plan

Hybrid/remote options

Paid time off

Job summary

Alliance Health is seeking an External Clinical Quality Analyst II to manage quality reviews for provider-led care management programs. The role emphasizes compliance with NCQA/CMS and state guidelines, with full-time remote work and some onsite travel within North Carolina.

Responsibilities include auditing care management documentation, analyzing program data, and training staff to close knowledge gaps. A NC clinical license or RN license is required, with three years of relevant experience.

Qualifications

• Knowledge of NC rules and requirements for the service continuum in North Carolina.
• Experience with Tailored Plan and Integrated Care processes.
• Experience with behavioral and physical health or IDD is a plus.

Responsibilities

• Analyze Care Management documentation to ensure compliance.
• Audit Care Management policy, staffing, training, and clinical documentation.
• Analyze program data to identify trends and implement corrective actions.
• Interpret qualitative and quantitative information to document findings and ensure contractual requirements are met.
• Identify system/operational issues hindering quality performance vs NCQA standards.

Skills

Strong clinical skills

Verbal and written communication

Analytical thinking

Problem solving

Time management

Education

Master’s degree in Health, Psychology, Sociology, Social Work, or a related Human Services field

North Carolina clinical license (LCSW, LCMHC, LMFT, LPA)

Registered Nurse (RN) license

Associates or higher in Nursing

Masters or higher in Human Services

Tools

Microsoft Excel

Microsoft Word

PowerPoint

SPSS

SurveyMonkey

Job description

The External Clinical Quality Analyst II 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 Evaluations, 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

Minimum Requirements

Education & Experience

Master’s degree in Health, Psychology, Sociology, Social Work, or another relevant Human Services field from an accredited college/university with a North Carolina Clinical license (LCSW, LCMHC, LMFT, LPA) and three (3) years of experience 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

Graduation from an accredited school of nursing with a Registered Nurse (RN) license and three (3) years of experience 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)

(3) years of experience providing care management to individuals in the following populations; Mental Health/Substance Use Disorders (MH/SUD), Severe Mental Illness (SMI), Intellectual/Developmental Disabilities (I/DD), Traumatic Brain Injuries (TBI), or Physical Health (PH)

Required experience

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

Medicaid Managed Care, or

Integrated care (behavioral and physical health), or

Program/services monitoring, program evaluation

Special Requirement

Current, active, unrestricted NC clinical license such as RN, LCSW, LMHC, or LMFT to practice as a health professional within the scope of licensure in the state of North Carolina.

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
• Strong verbal and written communication skills. Ability to write clear, accurate and concise rationale in support of findings.
• Ability to interpret contractual agreements, business-oriented statistics, medical/administrative services and records.
• Analytical skills and ability to make deductions; logical and sequential thinker.
• Problem solving and conflict resolution skills
• High degree of integrity and confidentiality required handling information that is considered personal and confidential.
• Highly effective communication skills
• Ability to manage time, prioritize work, and use problem-solving approaches

Salary Range

$69,592 - $88,729/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 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

• Associates or better in Nursing
• Masters or better in Human Services

Licenses & Certifications

Preferred

• Lic Clinical MH Counselor
• Lic Clinical Social Wkr
• Lic Marr & Family Ther
• Registered Nurse

Skills

Required

• Analysis
• Communication
• Conflict Resolution
• 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.