Provider Network Evaluator II-Clinical Quality

Alliance Health; Charlotte (NC); Remote; USD 61,000 - 78,000; Full time

Benefits offered by this job

Medical, Dental, Vision

Flexible work options

Paid time off

Dress flexibility

Job summary

Alliance Health is seeking a Provider Network Evaluator II-Clinical Quality Review (PNE II-CQR) to conduct and lead clinical quality reviews for MH/IDD/SUD providers within the Alliance Health network. This remote role requires NC licensure and NCIT within 6 months, with travel to Alliance offices and occasionally across North Carolina.

The role emphasizes leadership in reviews, case consultation, and ensuring adherence to clinical guidelines and regulatory compliance, while supporting team

Qualifications

• Master’s degree from an accredited college or university in a Human Services field.
• 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 National Certified Investigator and Inspector Training (NCIT) is required; must be completed within 6 months of hire.

Responsibilities

• Clinical Quality Reviews of MH/IDD/SUD Providers in the Alliance Health Network.
• Function as the clinical lead and team lead on Clinical Quality reviews, Oversight Reviews, and Plan of Correction Implementation reviews as assigned and required.
• Lead or participate in case consultation and peer review, provide guidance to team members, and promote inter-rater reliability through consistent application of review criteria and clinical principles.
• Ensure the application of best practice, established clinical guidelines and regulatory compliance by contracted Alliance providers.
• Review paid claims data, clinical documentation and personnel materials against best practice standards, policies and procedures, clinical coverage policies, administrative code, and regulatory guidance.
• Identify and clearly substantiate clinical quality concerns, health and safety risks, gaps in service planning, and regulatory or administrative noncompliance.
• Distinguish isolated deficiencies from systemic patterns, assess potential impact on members, provide clinically appropriate technical assistance, and monitor corrective actions through closure when a Plan of Correction is required.
• Interpret and apply the Provider Operations Manual, Clinical Coverage Policies, Scopes of Work (SOW), In Lieu of Services (ILOS), Provider contracts, and other governing standards to determine whether services are clinically appropriate and delivered as required.
• Report monitoring outcomes, including the potential impact to consumers and the Alliance Health network, to the Provider Network Evaluator Supervisor and the Director of Provider Network Evaluation.
• Use of advanced 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 preparation and development of standardized monitoring tools and guidelines.
• Assist in Department Policies, Procedures, and Standards.
• Assist in the development of clinical quality standards for service monitoring, overall 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, substance use, 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 teams and external Alliance units 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 providers, stakeholders, attend court hearings etc. is required as deemed necessary
• Minimum Requirements

Job description

The Provider Network Evaluator II-Clinical Quality Review (PNE II-CQR) holds and maintains clinical licensure as they are responsible for conducting as well as leading Clinical Quality Reviews (CQR), Oversight Reviews, and Plan of Correction implementation reviews of service providers contracted with Alliance Health. Clinical Quality Reviews are systematic MH/IDD/SUD service line evaluations that take into account member care, service delivery and implementation, adherence to rules and regulation where applicable and established clinical guidelines and principles of best practice. The PNE II-CQR leads, guides, supports, and peer reviews fellow team members work to ensure inter-rater reliability. Additionally, in limited situations, the PNE II-CQR may be assigned to investigate reported concerns to ensure individuals receive clinically sufficient, safe, and effective services rendered by providers in the Alliance Health network.

The PNE II-CQR position is fully remote. The selected candidate will work a designated schedule from their home office. Travel is required on an as-needed basis and may include visits to Alliance Health offices and, on rare occasions, travel to any of the 100 North Carolina counties served by Alliance members.

Candidates must reside within one of Alliance Health's catchment area counties: Cumberland, Durham, Harnett, Johnston, Mecklenburg, Orange, or Wake. Alternatively, candidates may live within approximately 60 miles of an Alliance office located in Wake, Johnston, or Cumberland County. Preference will be given to candidates residing in Mecklenburg County or surrounding areas in North Carolina.

Responsibilities and Duties

• Clinical Quality Reviews of MH/IDD/SUD Providers in the Alliance Health Network
• Function as the clinical lead and team lead on Clinical Quality reviews, Oversight Reviews, and Plan of Correction Implementation reviews as assigned and required
• Lead or participate in case consultation and peer review, provide guidance clinical assistance to team members, and promote inter-rater reliability through consistent application of review criteria and clinical principles
• Ensure the application of best practice, established clinical guidelines and regulatory compliance by contracted Alliance providers
• Review paid claims data, clinical documentation and personnel materials against best practice standards, policies and procedures, clinical coverage policies, administrative code, and regulatory guidance among other resources
• Identify and clearly substantiate clinical quality concerns, health and safety risks, gaps in service planning, and regulatory or administrative noncompliance
• Distinguish isolated deficiencies from systemic patterns, assess potential impact on members, provide clinically appropriate technical assistance, and monitor corrective actions through closure when a Plan of Correction is required
• Interpret and apply the Provider Operations Manual, Clinical Coverage Policies, Scopes of Work (SOW), In Lieu of Services (ILOS), Provider contracts, and other governing standards to determine whether services are clinically appropriate and delivered as required
• Report monitoring outcomes, including the potential impact to consumers and the Alliance Health network, to the Provider Network Evaluator Supervisor and the Director of Provider Network Evaluation
• Use of advanced 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 preparation and development of standardized monitoring tools and guidelines

Assist in Department Policies, Procedures, and Standards

• Assist in the development of clinical quality standards for service monitoring, overall 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, substance use, 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 teams and external Alliance units 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 providers, stakeholders, attend court hearings etc. is required as deemed necessary

Minimum Requirements

Required:

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.

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 evidence-based practices, levels of care, service planning, DSM criteria and professional communication and writing skills are necessary
• Prior monitoring, clinical auditing and/or quality assurance is desired as is familiarity with Medicaid funded MH/IDD/SUD services
• Knowledge of Clinical Coverage Policies, Records Management and Documentation Management
• 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

Salary Range

$61,439 - $78,335/Annual

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