Provider Network Evaluator I, Targeted Monitoring

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

📋 Description

• Execute targeted and thorough monitoring of care quality, health and safety, incident reports, service delivery, Medicaid contracts, state funding compliance, provider operations, and other pertinent issues.

• Formulate monitoring plans derived from referrals, internal documents, allegations, and recognized concerns.

• Develop review tools tailored to each specific targeted or focused monitoring activity.

• Request, gather, document, inventory, and securely store clinical records, medical records, personnel records, policies, procedures, quality management plans, and other relevant evidence.

• Conduct interviews with internal staff, provider staff, former employees, service recipients, and additional relevant individuals.

• Identify findings of noncompliance, health and safety risks, overpayments, and irregularities; ascertain whether allegations are substantiated.

• Record and monitor audit activities from referral to final resolution.

• Document allegations, communications, investigative efforts, reviews, and findings in comprehensive audit/investigation reports.

• Lead reviews or collaborate with the PNE Targeted Team.

• Investigate clinical coverage policies, administrative codes, bulletins, scopes of work, service manuals, provider operation manuals, and federal/state legislation.

• Present review findings and disposition recommendations to leadership, compliance committees, and general counsel when necessary.

• Provide updates on case status and deliver oral or written reports to stakeholders.

• Interpret and relay highly technical information effectively.

• Review claims, authorizations, credentialing/enrollment, Jiva, grievances, previous audits/investigations, incident reports, and policies/procedures.

• Utilize MicroStrategy reports throughout pre-investigation and investigation phases.

• Analyze claims data and authorizations to uncover irregularities and issues.

• Prepare charts for improper payments and statements of deficiency; offer feedback and technical assistance to providers.

• Follow up on corrective measures and engage in provider appeals, reconsiderations, and court hearings.

• Suggest revisions to Alliance Health procedures and policies.

• Consult with Corporate Compliance and report suspected fraud, waste, or abuse to Special Investigations.

• Perform additional duties as assigned by the Supervisor.

⛳️ Requirements

• Bachelor’s degree in human services or social sciences from an accredited college or university.

• Five (5) years of post-degree experience in healthcare compliance, provider monitoring, policy development, auditing, investigations, accreditation, or a comparable combination of related training and experience.

• NCIT preferred but not mandatory; must be completed successfully within 6 months of hire.

• Preferred knowledge of the healthcare industry and/or Medicare/Medicaid/Behavioral Health.

• Proficient understanding of claims adjudication standards and procedures.

• Familiarity with state and federal Medicaid laws, regulations, policies, rules, guidelines, service limitations, and Medicaid programs.

• Knowledge of Alliance Health service benefit plans and network providers.

• General understanding of MCO functions related to prior authorization, utilization reviews, grievance management, provider credentialing, and monitoring.

• Proficient in using Microsoft Office products, including Word, Excel, and Outlook.

• Excellent verbal and written communication skills.

• Capability to write clear, accurate, and concise rationales supporting findings.

• Strong analytical, deductive, logical, and sequential thinking abilities.

• Ability to identify resources, gather evidence, analyze raw data, and generate reports.

• Proficient in interpreting contractual agreements, business-oriented statistics, medical/administrative services, and records.

• High level of integrity, discretion, and confidentiality.

• Competence in time management, prioritization, and employing problem-solving methods.

• Knowledge of investigative techniques and procedures.

🏝️ 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, holidays, and management leave.

• Dress flexibility.