[Hiring] External Clinical Quality Analyst II @Alliance Health

Role 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.

• Analyze Care Management documentation and activities to ensure compliance.
• Review the quality of provider-led Care Management programs by completing administrative reviews 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.

Qualifications

• 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).

Requirements

• Experience with Care plans, comprehensive assessments, care management interventions, and service engagement activities.
• Medicaid Managed Care experience.
• Integrated care (behavioral and physical health) experience.
• Program/services monitoring and program evaluation experience.

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.
• Proficiency in 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.

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.