Provider Network Evaluator II-Clinical Quality (Full Time, Remote, North Carolina Based)

About the role

The Provider Network Evaluator II-Clinical Quality Review (PNE II-CQR) holds and maintains clinical licensure as they are responsible for conducting as well as leading Clinical Quality Reviews (CQR), Oversight Reviews, and Plan of Correction implementation reviews of service providers contracted with Alliance Health. Clinical Quality Reviews are systematic MH/IDD/SUD service line evaluations that take into account member care, service delivery and implementation, adherence to rules and regulation where applicable and established clinical guidelines and principles of best practice. The PNE II-CQR leads, guides, supports, and peer reviews fellow team members work to ensure inter-rater reliability. Additionally, in limited situations, the PNE II-CQR may be assigned to investigate reported concerns to ensure individuals receive clinically sufficient, safe, and effective services rendered by providers in the Alliance Health network. The PNE II-CQR position is fully remote. The selected candidate will work a designated schedule from their home office. Travel is required on an as-needed basis and may include visits to Alliance Health offices and, on rare occasions, travel to any of the 100 North Carolina counties served by Alliance members. Candidates must reside within one of Alliance Health's catchment area counties: Cumberland, Durham, Harnett, Johnston, Mecklenburg, Orange, or Wake. Alternatively, candidates may live within approximately 60 miles of an Alliance office located in Wake, Johnston, or Cumberland County. Preference will be given to candidates residing in Mecklenburg County or surrounding areas in North Carolina.

Responsibilities

• Clinical Quality Reviews of MH/IDD/SUD Providers in the Alliance Health Network
• Function as the clinical lead and team lead on Clinical Quality reviews, Oversight Reviews, and Plan of Correction Implementation reviews as assigned and required
• Lead or participate in case consultation and peer review, provide guidance clinical assistance to team members, and promote inter-rater reliability through consistent application of review criteria and clinical principles
• Ensure the application of best practice, established clinical guidelines and regulatory compliance by contracted Alliance providers
• Review paid claims data, clinical documentation and personnel materials against best practice standards, policies and procedures, clinical coverage policies, administrative code, and regulatory guidance among other resources
• Identify and clearly substantiate clinical quality concerns, health and safety risks, gaps in service planning, and regulatory or administrative noncompliance
• Distinguish isolated deficiencies from systemic patterns, assess potential impact on members, provide clinically appropriate technical assistance, and monitor corrective actions through closure when a Plan of Correction is required
• Interpret and apply the Provider Operations Manual, Clinical Coverage Policies, Scopes of Work (SOW), In Lieu of Services (ILOS), Provider contracts, and other governing standards to determine whether services are clinically appropriate and delivered as