Provider Network Evaluator II-Clinical Quality Review; Hybrid, North Carolina

Position Overview

Provider Network Evaluator II-Clinical Quality Review (Hybrid, North Carolina Based) (Biotech)

The Provider Network Evaluator II-Clinical Quality Review performs Clinical Quality Reviews (CQR), Oversight Reviews, and plan of correction implementation reviews of service providers contracted with Alliance Health. In limited situations, the evaluator may investigate instances of concern to ensure individuals receive sufficient, safe, and effective services rendered by providers in the Alliance Health network.

This is a full-time hybrid position. Weekly travel is required to conduct on-site reviews. The selected candidate must reside within the following Alliance catchment area counties:
Cumberland, Durham, Harnett, Johnston, Orange, or Wake, or live approximately 60 miles from an Alliance office located in Wake, Johnston, and Cumberland counties.

• Conduct clinical quality reviews and Oversight Reviews as required and assigned.
• Review paid claims data, clinical documentation and personnel materials against best practice standards, policies and procedures, clinical coverage policies, administrative code, regulatory guidance, and other resources.
• Identify out of compliance findings, clinical concerns and other findings and provide technical assistance and/or oversight of the plan of correction (POC) process for those network providers with systemic findings.
• Review Provider Operations Manual, Scopes of Work (SOW), In Lieu of Services (ILOS) and Provider contracts for additional requirements in the delivery of services and care.
• Report monitoring outcomes and the potential impact on consumers to the Provider Network Evaluator Supervisor and the Director of Provider Network.
• Use clinical expertise and knowledge of best practice and treatment modalities to effectively interpret qualitative and quantitative provider information to appropriately support and document findings.
• Develop and assist in the creation of standards for service monitoring, quality improvement and evaluating the delivery of services to consumers and families.
• Assist in the development of monitoring policies and procedures pertaining to behavioral health and I‑DD services.
• Maintain a provider database that includes information gathered from monitoring activities and assist in the development of quality indicators and Provider profile elements for the Provider database in collaboration with Service Management.
• Acquire and maintain knowledge of current services and supports available within the Alliance catchment area and available to consumers within North Carolina.
• Provide technical assistance to providers, stakeholders and internal Alliance Health departments as requested and needed.
• Support PNE CQR teams by sharing clinical information and knowledge as needed in a formal and ad‑hoc manner.
• Travel between Alliance offices, attend meetings on behalf of Alliance, participate in Alliance-sponsored events, meet with members, providers, stakeholders, and attend court hearings as required.

• Master’s degree from an accredited college or university in a Human Services field (e.g., Psychology, Social Work).
• A minimum of three (3) years post‑master’s degree progressive experience in the field of mental health, developmental disabilities, or substance abuse.
• Valid driver’s license and good driving record.
• Full, current, and active NC license as an LCSW, LCAS, LCMHC, LPA, or LMFT.
• Knowledge of evidence-based practices, levels of care, service planning, DSM criteria, and professional communication and writing skills.
• National Certified Investigator and Inspector Training (NCIT) completed within 6 months of hire and meeting the 1‑year employment requirements as a regulatory investigator/inspector.

• 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.
• Thorough clinical knowledge and understanding of the principles, concepts, and best practices used in the treatment, habilitation, and support of individuals…