What are the responsibilities and job description for the Provider Network Evaluator I - Routine Monitoring-Full time Hybrid NC Based Role position at Alliance Health?
The Provider Network Evaluator I - Routine Monitoring, performs routine and post-payment monitoring, performance profile reviews and in limited situations, may investigate instances of concerns to ensure individuals receive sufficient, safe, and effective services from providers in the Alliance network.
This is a full-time hybrid position. You must live within a 60-mile radius of one of our Alliance offices. There will be occasions of on-site meetings and provider office clinical quality reviews with given notice from department head.
Responsibilities and Duties
Ensure programs, services, and systems are provided in accordance with Alliance Health, Local, State and Federal Standards
- Conduct routine provider monitorings and post-payment reviews
- Interpret qualitative and quantitative provider information to appropriately document findings
- Review and acquire knowledge and understanding of State Plan documents, MCO Business Plan, Provider contracts, Provider Operations Manual, Records Management and Documentation Manual, Scopes of Work, and Clinical Service Guidelines to ensure provider services comply with standards
- Provide reports to include, but not limited to, statement of deficiencies and improper payment charts on outcomes of monitoring and the potential impact on consumers involved to the Provider Network Evaluator Supervisor
- In limited instances may investigate those findings and results from a routine and/or post-payment monitoring that fall outside of required monitoring activities
Assist in department policies, procedures, and standards
- Assist in the development 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
Provide monitoring information for inclusion in Provider database
- Work with Provider Network Team to maintain a provider database which will include information gathered from monitoring activities
- Assist in the development of quality indicators and Provider profile elements for the Provider database, in collaboration with the Service Management
Maintain knowledge of current services and supports available
- Acquire and maintain knowledge of the current services and supports available within the catchment area and available to consumers within North Carolina
- Provide technical assistance to providers, stakeholders and internal Alliance Health units as requested and as needed
Minimum Requirements
Bachelor’s degree in human services or social sciences from an accredited College/University and three (3) years of post-degree of experience in healthcare compliance, provider monitoring, policy development, auditing, investigations, accreditation or any equivalent combination of related training and experience.
The National Certified Investigator and Inspector Training (NCIT) must be successfully completed within six (6) months of hire.
Knowledge, Skills, and Abilities
- 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
- Knowledge and understanding of the principles, concepts and Best Practices used in the treatment, habilitation and support of individuals with needs in any of the disability areas
- High level of diplomacy and discretion
- Strong mediation skills
- Excellent team building skills
- Effective communication skills
- Ability to identify/analyze administrative problems pertinent to the contract
- Ability to make independent judgments, logical conclusions, recommendations and decisions
- Ability to determine the appropriate course of action in an emergency or stressful situation
- Ability to maintain confidentiality both of consumer data and provider business practices
- Ability to review and analyze data in an effort to evaluate program effectiveness, progress, problems and system performance
- Ability to work effectively with others internally and externally
Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.
Compensation
$25.00-$31.88 hourly
An excellent fringe benefit package accompanies the salary, which includes:
- 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 : $25 - $32
