Provider Network Evaluator II – Clinical Quality

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

📋 Description

• Conduct and oversee Clinical Quality Reviews, Oversight Reviews, and reviews of Plan of Correction implementations for contracted MH/IDD/SUD service providers.

• Lead, mentor, and support team members in their work to ensure consistency in evaluations.

• Ensure that contracted providers adhere to best practices, clinical guidelines, and regulatory standards.

• Analyze paid claims data, clinical documentation, and personnel materials against relevant standards, policies, procedures, and regulations.

• Identify and validate clinical quality issues, health and safety risks, service-planning deficiencies, and instances of regulatory or administrative noncompliance.

• Differentiate between isolated deficiencies and systemic issues while assessing their potential impact on members.

• Provide technical guidance and monitor corrective actions until resolution when a Plan of Correction is necessary.

• Interpret provider manuals, clinical coverage policies, scopes of work, ILOS, contracts, and governing standards.

• Communicate monitoring results and potential implications to the Provider Network Evaluator Supervisor and Director of Provider Network Evaluation.

• Utilize advanced clinical expertise and treatment modality knowledge to interpret provider information and document findings.

• Assist with standardized monitoring tools, guidelines, departmental policies, procedures, standards, and clinical quality benchmarks.

• Develop monitoring policies and procedures for behavioral health, substance use, and I-DD services.

• Maintain provider database information collected from monitoring activities.

• Collaborate with Service Management to develop quality indicators and elements for provider profiles.

• Stay informed about services and supports available within the Alliance catchment area and throughout North Carolina.

• Provide technical assistance to providers, stakeholders, and internal Alliance Health departments.

• Support Provider Network Evaluation teams and external Alliance units by sharing clinical insights.

• Travel between Alliance offices, engage with providers and stakeholders, and attend meetings, events, and court hearings as required.

⛳️ Requirements

• Master’s degree from an accredited college or university in a Human Services field (e.g., Psychology, Social Work, etc.).

• A minimum of three (3) years of progressive experience in the fields of mental health, developmental disabilities, or substance abuse following the master's degree.

• Must possess a valid driver’s license and maintain a good driving record.

• A full, current, and active NC license as an LCSW, LCAS, LCMHC, LPA, or LMFT is required.

• Completion of National Certified Investigator and Inspector Training (NCIT) is mandatory; NCIT must be successfully completed within 6 months of hire and must meet the 1-year employment requirement as a regulatory investigator/inspector.

• A working knowledge of federal and state statutes, rules, definitions, and regulations governing MHDDSAS services is essential.

• Familiarity with evidence-based practices, levels of care, service planning, DSM criteria, and professional communication and writing.

• Understanding of Clinical Coverage Policies, Records Management, and Documentation Management.

• Knowledge of Mental Health, Developmental Disabilities, and Substance Abuse areas.

• Comprehensive clinical knowledge of treatment, habilitation, and support principles, concepts, and best practices.

• A high level of diplomacy and discretion is necessary.

• Strong mediation and team-building skills are required.

• Excellent communication abilities are essential.

• Capability to identify and analyze administrative issues relevant to the contract.

• Ability to make independent judgments, logical conclusions, recommendations, and decisions.

• Proficient in determining appropriate actions in emergency or high-pressure situations.

• Ability to maintain confidentiality regarding consumer data and provider business practices.

• Competence in reviewing and analyzing data to assess program effectiveness, progress, challenges, and system performance.

• Ability to work effectively with both internal and external stakeholders.

🏝️ Benefits

• Comprehensive medical, dental, vision, life, and long-term disability coverage.

• Generous retirement savings plan.

• Flexible work schedules, including hybrid and remote options.

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

• Dress code flexibility.