[Hiring] Provider Network Evaluator I @Alliance Health

Role Description

The PNE Targeted Reviewer I is responsible for conducting focused and targeted reviews that may include health and safety reviews, quality of care issues, intensive incident report reviews, and the appropriateness of clinical services delivered by providers in the Alliance network. The PNE Targeted Reviewer I is required to review claims data, clinical documentation, provider contracts, policies, and procedures, conduct provider staff and stakeholder interviews, review reference and regulatory materials, to identify out of compliance findings, overpayments, quality of care and health and safety issues, clinical concerns, and other irregularities. Due to the varying nature of Targeted Reviews, the PNE I Targeted Reviewer is responsible for the development of review tools specific to the scope of the review.

The PNE I-Targeted is a remote position; however, travel is required on an as-needed basis to conduct on-site reviews, monitoring, and training.

Responsibilities and Duties

• Conduct targeted and focused monitoring to include reviewing allegations related to:
  • Quality of care
  • Health and safety
  • Incident reports
  • Compliance with service delivery
  • Adherence to Medicaid contract and State funding
  • Provider operation expectations
• Develop targeted and focused monitoring plans based upon:
  • Referrals
  • Internal documents and supporting materials
  • Allegations
  • Additional identified concerns
• Create and develop review tools specific to the targeted and focused monitoring.
• Request and/or accurately collect, document, inventory, and store evidence, including:
  • Clinical and medical records
  • Personnel records
  • Policies/procedures
  • Quality management plans
• Conduct interviews with:
  • Internal employees
  • Provider employees
  • Former employees
  • Recipients of services
  • Other individuals
• Identify out of compliance findings, health and safety issues, overpayments, and other irregularities.
• Record and track all monitoring and audit activities from referral to final disposition.
• Document allegations, communications, investigative activities, and findings in a detailed audit/investigation report.
• Function as review lead and/or collaborate with the PNE Targeted Team.
• Diligently research clinical coverage policies, administrative code, bulletins, and federal/state laws.
• Present focused and targeted review findings and make disposition recommendations.
• Conduct and participate in Targeted and Focused monitoring planning meetings.
• Review data from various sources to inform decision making and monitoring recommendations.
• Document Improper Payment Charts and provide feedback to providers.
• Follow up on provider corrective actions through the POC implementation and probation process.
• Prepare for and participate in provider appeal processes and court hearings.
• Recommend revisions to Alliance Health procedures and policies.
• Recognize when fraud, waste, and abuse are present and refer to the Special Investigations unit.
• Perform other job-related duties as assigned by the Supervisor.

Qualifications

• Bachelor’s degree in human services or social sciences from an accredited College/University.
• Five (5) years of post-degree experience in healthcare compliance, provider monitoring, policy development, auditing, investigations, or equivalent training and experience.
• The National Certified Investigator and Inspector Training (NCIT) is preferred, but not required. NCIT must be successfully completed within 6 months of hire.

Requirements

• Health care industry and/or Medicare/Medicaid/Behavioral Health knowledge preferred.
• Knowledge and proficiency in claims adjudication standards & procedures preferred.

Knowledge, Skills, and Abilities

• Knowledge of state and federal Medicaid laws, regulations, policies, and guidelines.
• Knowledge and proficiency in claims adjudication standards & procedures.
• Knowledge of the Alliance Health service benefit plans and network providers.
• General understanding of major MCO functions related to prior authorization, utilization reviews, grievance management, and provider credentialing.
• Skill in using Microsoft Office products (Word, Excel, Outlook, etc.).
• Strong verbal and written communication skills.
• Analytical skills and ability to make deductions; logical and sequential thinker.
• Ability to identify resources, gather evidence, analyze raw data, and generate reports.
• Ability to interpret contractual agreements and business-oriented statistics.
• High degree of integrity, discretion, and confidentiality required.
• Ability to manage time, prioritize work, and use problem-solving approaches.
• Knowledge of investigative methods and procedures.

Salary Range

$29.54 - $37.66/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