[Hiring] Provider Network Evaluator II-Targeted @Alliance

Role Description

The PNE Targeted Reviewer II holds and maintains clinical licensure and is responsible for conducting focused and targeted reviews that may include health and safety reviews, quality of care issues, intensive incident report reviews, and determines the appropriateness of clinical services delivered by providers in the Alliance network. This position is full-time remote. Selected candidate must reside in North Carolina and within 60-mile radius of any of Alliance Office. Some travel for onsite meetings may be required.

• Conduct health and safety reviews, quality of care issues, and intensive incident report reviews.
• Review claims data, clinical documentation, provider contracts, policies, and procedures.
• Conduct provider staff and stakeholder interviews.
• Identify out of compliance findings, overpayments, quality of care and health and safety issues, clinical concerns, and other irregularities.
• Develop review tools specific to the scope of the review.

Qualifications

• Master’s degree in human services/social sciences from an accredited College/University.
• Five (5) years post-Master’s experience in healthcare compliance, monitoring, policy development, auditing, quality improvement/quality assurance, regulatory management, investigations, accreditation, analytics, government/public administration and/or auditing.
• Must have a current, active NC license as a LCSW, LCMHC, LPA, LMFT, or LCAS.
• The National Certified Investigator and Inspector Training (NCIT) is preferred, but not required. NCIT must be successfully completed within 6-months of hire.

Requirements

• Knowledge of state and federal Medicaid laws, regulations, policies, rules, guidelines, service limitations, and various Medicaid programs.
• Knowledge and proficiency in claims adjudication standards & procedures.
• Knowledge of investigative methods and procedures.
• Knowledge of the Alliance Health service benefit plans and network providers.
• Skill in using Microsoft Office products (such as Word, Excel, Outlook, etc.).
• Strong verbal and written communication skills.
• Analytical skills and ability to make deductions; logical and sequential thinker.
• High degree of integrity and confidentiality required handling information that is considered personal and confidential.
• Ability to manage time, prioritize work, and use problem-solving approaches.

Benefits

• Medical, Dental, Vision, Life, Long and Short 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.

Salary Range

$68,227 - $86,990/Annually. Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.