[Hiring] Provider Network Evaluator I-HCBS @Alliance

Role Description

The Provider Network Evaluator I-HCBS works as part of the Provider Network Evaluation (PNE) Department on the Home and Community Based Services (HCBS) team. Home and Community Based Services provide opportunities for Medicaid beneficiaries to receive services in their own home or in community settings instead of institutional settings. The Home and Community Based Services team is responsible for conducting reviews of Unlicensed Alternatives to Family Living placements for Alliance members, and reviews of member self-directed services (Employee of Record) as described in CCP8P, Attachment H, and service delivery under 1915(i) waiver. The PNE I-HCBS will also be involved in ensuring that HCBS final rule requirements are followed, to include ensuring validation of agency self-assessments and that member surveys are remediated when follow-up is required.

The PNE I-HCBS is a remote position; however, travel is required at least weekly to conduct on-site reviews and monitoring. Travel to Alliance Health office in Mecklenburg County is required as needed.

Responsibilities & Duties

• Validate and Approve TBI, Innovation Waiver, 1915(i), and LTCS Sites and Services
• Develop and maintain knowledge of HCBS Final Rule, HCBS Standard Operating Procedure, 1915(i) Waiver, Clinical Coverage Policy, NC Administrative Code, Records Management and Documentation Manual and other regulatory resources and guidelines to ensure standards and requirements are in compliance
• Review and validate service site documentation for TBI, Innovation Waiver, 1915(i), and LTCS programs; confirm compliance with regulatory standards to authorize member access to new or existing service locations
• Perform HCBS reviews as required and within the required timeframes
• Review provider policies and procedures for compliance with CMS mandated HCBS standards
• Review and manage HCBS portal to ensure portal entries are reviewed and accepted prior to service initiation and move in
• Collaborate with other MCOs when a member is transferred into the Alliance catchment area or transferred out of the Alliance catchment area
• Work with providers to ensure out of compliance findings are remedied either by providing technical assistance and/or through a plan of correction
• Work with I/DD Care Coordination, Provider Network Development and agency providers to ensure sites are validated and in compliance
• Remediate issues and concerns that are identified by the State with MIE surveys through documentation review, technical assistance with providers and other stakeholders, and collaboration with I/DD Care Coordinators
• Provide reports and updates on outcomes of reviews of HCBS and the potential impact on consumers involved to the Provider Network Evaluator Supervisor and/or the Director of Network Evaluation
• Review and Monitor Unlicensed Alternative to Family Living
• Follow UAFL monitoring desk procedures for Unlicensed Alternative to Family Living placements for annual reviews and initial reviews
• Ensure the site is contracted and provider is credentialed
• Review UAFLs on annually and conduct initial site reviews as required using the UAFL tool with special attention to member health, safety and protection of client rights
• Immediately address health, safety and quality of care issues for Alliance Health members when identified
• When out of compliance findings are identified, work with the provider to remedy via technical assistance and/or Plan of Correction
• Maintain and update service sites and member locations as necessary
• Review and Monitor Individual and Family Directed Services
• Review self-directed services (Employer of Record) on an annual basis as required
• Provide technical assistance when required to ensure compliance with CCP8-P, Attachment H and other mandated requirements as identified in rule, regulation and IFDS handbook
• When out of compliance findings are identified, work with the provider to remedy via technical assistance and/or Plan of Correction
• Maintain EOR spreadsheet and required monitoring folders
• Assist With Department Policies, Procedures, and Standards
• Assist in the development and maintenance of standards for HCBS and unlicensed AFLs sites, Individual and Family Directed Services (IFDS), quality improvement and evaluating the delivery of services to consumers and families
• Assist in the development of monitoring policies and procedures and site validation
• Assist in the development of MIE survey processes and procedures
• Provide Monitoring Information for Inclusion in Provider Database
• Maintain a current database of HCBS sites that require monitoring and review
• Maintain a database of unlicensed AFL sites that require annual reviews
• Work with I/DD care coordination as needed to update the database to capture sites that are new and sites that are no longer serving members
• Help maintain the database to ensure accuracy
• Track any discrepancies and errors in State required reports and reconcile as needed to ensure sites are validated and there are no disruptions in services
• Track I/DD Care Coordination HCBS assessments/reviews and communicate any discrepancies as needed
• Maintain Knowledge of Rules, Regulations, Services and Supports Available
• Acquire and maintain knowledge of the current services and supports available within the catchment area and available to consumers within North Carolina
• Develop and maintain knowledge of HCBS Final Rule HCBS Standard Operating Procedure and their application
• Develop and maintain knowledge of 1915 (i) waiver and Clinical Coverage Policies
• Acquire knowledge and understanding of regulation, rules and requirements for member service
• Participate in Investigations and Focused Reviews
• In limited instances, the PNE I may be asked to participate in investigations and focused reviews when there are concerns about quality of care and health and safety
• Travel
• Travel between Alliance offices, attending meetings on behalf of Alliance, participating in Alliance sponsored events, etc. may be required
• Travel to review sites, meet with members, providers, stakeholders, and attend court hearings etc. is required

Qualifications

• A bachelor’s degree in a Human Service field (such as Psychology, Social Work, etc.)
• At least five (5) years of progressive experience in the field of I/DD or TBI
• Strong knowledge of I/DD and TBI services required
• Must maintain a valid driver’s license and a good driving record
• The National Certified Investigator and Inspector Training (NCIT) is required
• The PNE I candidate must be able to complete and pass the course within 6 months of hire and meet the 1-year employment requirement as a regulatory investigator/inspector

Preferred Qualifications

• Experience with Home Based and Community Services (HCBS) is highly desired

Knowledge, Skills, & 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
• Extensive knowledge of I/DD and TBI services and requirements
• 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
• Microsoft Office 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 in an effort to evaluate program effectiveness, progress, problems and system performance
• Ability to work effectively with others internally and externally

Salary Range

$26.27 -$33.49/Hourly. Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.

Benefits

• 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