External Clinical Quality Analyst I

This is a fully remote position, open to applicants in North Carolina.

📋 Description

• Oversee the quality assessment process for care management programs led by providers.

• Perform both administrative and detailed clinical case evaluations to ensure compliance with the NC DHHS Tailored Care Management Provider Manual.

• Review policies, procedures, staffing, training, activities, and clinical documentation related to provider-led care management.

• Evaluate adherence to program descriptions, workflows, evidence-based clinical guidelines, NCQA standards, CMS regulations, and other regulatory frameworks.

• Analyze program data, recognize trends, and devise and implement corrective action plans.

• Interpret both qualitative and quantitative data, document findings, and ensure that contractual obligations are fulfilled.

• Identify systemic and operational challenges that impact quality performance metrics.

• Provide written assessments to the Senior Director of Network Evaluation, the Practice Transformation Team, and Compliance regarding quality issues and compliance risks/trends.

• Assess knowledge gaps among provider-led care management staff and coordinate training opportunities with relevant leadership teams.

• Travel to various Alliance offices and participate in meetings, events, and court hearings as necessary.

⛳️ Requirements

• Bachelor’s degree in a non-Human Services field with four (4) years of experience in providing care management for individuals with TBI, I/DD, MH/SUD, SMI, or PH; OR

• Bachelor’s degree in a Human Services field with three (3) years of experience in providing care management for individuals with TBI, I/DD, MH/SUD, SMI, or PH; OR

• Bachelor’s degree in a Human Services field with three (3) years of experience conducting provider monitoring/investigations or program evaluation activities.

• Proficiency in developing or reviewing care plans, comprehensive assessments, care management interventions, and service engagement activities.

• Familiarity with Medicaid Managed Care.

• Experience in integrated care (behavioral and physical health) or program/services monitoring and evaluation.

• Understanding of North Carolina state and federal guidelines and requirements concerning the service continuum.

• Knowledge of Tailored Plan, Integrated Care, and Care Management processes along with regulatory requirements.

• Awareness of best practices and promising strategies for behavioral and physical health and/or intellectual/developmental disabilities.

• Proficiency in Microsoft Excel, Word, PowerPoint, SPSS, and Survey Monkey or similar online survey tools.

• Strong skills in clinical analysis, problem-solving, conflict resolution, interpersonal relations, diplomacy, discretion, communication, negotiation, and issue resolution.

• Preferred: Experience in auditing clinical documentation.

• Preferred certification: Certified Care Manager (CCM).

🏝️ Benefits

• Medical, Dental, Vision, Life, and Long Term Disability insurance.

• Generous retirement savings plan.

• Flexible work schedules, including hybrid and remote options.

• Paid time off encompassing vacation, sick leave, holidays, and management leave.

• Dress flexibility.