Provider Network Quality Assurance Specialist (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, Life, Long‑to

Hybrid/Remote options

Retirement savings plan

PTO incl. vacation, sick, holiday

Dress flexibility

Job summary

Alliance Health is seeking a Provider Network Quality Assurance Specialist to monitor, audit, and improve the quality and compliance of provider network operations. This remote role requires North Carolina residence with possible onsite meetings in Morrisville.

The position emphasizes audit scheduling, data analysis, and maintaining robust documentation to support regulatory reviews and process improvements.

Qualifications

• Bachelor’s degree in related field with at least five years of QA/improvement experience.
• Excel proficiency to analyze data and produce graphs and tables.

Responsibilities

• Conduct Quality Audits of Provider Network Operations Processes.
• Develop and maintain an audit schedule; analyze data and make recommendations.
• Maintain audit evidence and records for review readiness.
• Review Provider Records, Contracts, and Enrollment Documentation for accuracy; document trends.
• Validate compliance with DHB, NCQA, State, and organizational requirements; document gaps and risks.
• Perform root cause analysis and track corrective actions with accountable teams.

Skills

Quality Assurance

Data Analysis

Auditing

Excel

Project Management

Communication

Education

Bachelor’s Degree in Sociology

Bachelor’s Degree in Psychology

Bachelor’s Degree in Public Health

Bachelor’s Degree in Statistics

Bachelor’s Degree in Economics

Bachelor’s Degree in Business Administration

Tools

Salesforce

Alliance Claims System (ACS)

Job description

The Provider Network Quality Assurance Specialist is responsible for monitoring, auditing, and improving the quality, accuracy, and compliance of provider network operations. The role supports provider data integrity, regulatory compliance, provider directory accuracy, and continuous process improvement.

This position is fulltime remote. Selected candidate must reside in North Carolina. Some travel for onsite meetings to the Home office (Morrisville, NC) may be required.

Responsibilities & Duties

Conduct Quality Audits of Provider Network Operations Processes

• Develop and maintain an audit schedule
• Conduct research, analyze data, and make recommendations regarding administrative, organizational, and operational problems
• Maintain audit evidence and records to support internal and external review readiness

Support Provider Directory Accuracy and Provider Data Validation Initiatives

• Perform reviews of Provider Directory accuracy and maintain written documentation of reviews and subsequent follow up that will meet both DHB and NCQA requirements
• Compare published information with source systems
• Coordinate provider outreach or internal research to resolve unverified or conflicting information
• Prioritize corrections that could affect member access, search results, or regulatory compliance
• Perform root cause analysis, track corrective actions and provide results
• Cultivate and encourage efforts to expand cross-team collaboration and partnership

Review Provider Records, Contracts, and Enrollment Documentation

• Perform reviews of provider data in Salesforce, Alliance Claims System (ACS) and enrollment and contracting data to identify any trends and document
• Confirm that contract terms, effective dates, network participation, locations, and reimbursement attributes are accurately recorded
• Compare system entries with applications, contracts, enrollment requests and approved change requests
• Identify missing, expired, inconsistent, duplicate, or incorrectly entered information
• Route discrepancies to the appropriate owner and track corrections through completion

Validate Compliance With DHB, NCQA, State, and Organizational Requirements

• Maintain current audit criteria based on applicable regulatory, accreditation, contractual, and internal policy requirements
• Document compliance gaps, assess risk, and escalation significant findings promptly
• Support regulatory requirements, accreditation reviews, and internal compliance assessments by gathering required data and responding to requests

Perform Root Cause Analysis and Track Corrective Actions

• Analyze errors and recurring themes using appropriate root cause methods
• Partner with accountable teams to define corrective and preventive actions, owners, milestones, and due dates
• Document all analysis

Minimum Requirements

Education & Experience

Required

Bachelor’s Degree in human services; Sociology, Psychology, Public Health, Statistics, Economics, Business Administration or related social science field from an accredited college/university and at least five (5) years of related experience providing quality assurance/improvement activities.

Experience leading project teams focused on quality improvement projects required. Excel proficiency is required to analyze data and to produce graphs and tables.

Preferred

Prior experience in Managed Care preferred.

Knowledge, Skills, & Abilities

• Superior communication and writing skills.
• Strong organization and time management skills.
• Advance Knowledge of Microsoft office applications, including Excel.
• Proficiency in MicroStrategy or other statistical or data modeling programs.
• Experience developing quality improvement plans for services to persons with complex needs including physical health, behavioral health, and social determinant of health needs.
• Experience with project management processes.
• Ability to manage multiple projects.
• Ability to work with all stakeholders: members, network providers, families, and government staff in a caring and respectful manner, and with due understanding of and consideration for cultural differences.
• Flexibility and willingness to learn new knowledge and skills.

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

Required

• Bachelors or better in Sociology
• Bachelors or better in Psychology
• Bachelors or better in Public Health
• Bachelors or better in Statistics
• Bachelors or better in Economics
• Bachelors or better in Business Administration

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.