Alliance Health in
External Clinical Quality Analyst I (Full-time Remote, North Carolina Based)
Alliance Health in, Morrisville, North Carolina, United States, 27560
External Clinical Quality Analyst I (Full-time Remote, North Carolina Based) (Biotech)
The External Clinical Quality Analyst I manages the quality review process for provider-led care management programs. Incumbents conduct quality reviews and audits of provider-led care management programs and processes for quality assurance purposes and to support the effective functioning of provider-led care management.
This position is full-time remote and selected candidates must reside in North Carolina. Some travel for onsite meetings to the home office may be required.
Responsibilities Analyze Care Management Documentation and Activities to Ensure Compliance
Review the quality of provider-led Care Management programs by completing administrative reviews coupled with detailed clinical case reviews for alignment with all requirements identified in the NC DHHS Tailored Care Management Provider Manual.
Audit provider-led Care Management policy and procedures, staffing, training, and provision of all Care Management activities including clinical documentation to ensure alignment with program descriptions, workflows, evidence‑based clinical guidelines, NCQA guidelines, CMS guidelines, and regulatory guidelines (when applicable).
Analyze program data to identify trends and develop and implement corrective action plans as appropriate.
Interpret qualitative and quantitative information to document findings and ensure contractual requirements are met.
Identify system and/or operational issues hindering the attainment of quality performance standards as defined by NCQA standards, applicable state and Federal laws and regulations.
Analyze Data and Report on Findings
Provide written feedback to the Senior Director of Network Evaluation, Practice Transformation Team, and Compliance concerning quality concerns pertaining to program performance and compliance risks/trends.
Evaluate Knowledge Gaps of Staff and Coordinate Training
Evaluate knowledge gaps of the provider-led Care Management staff and collaborate with Provider Network, Practice Transformation and Care Management Leadership to coordinate learning and training opportunities for provider-led Care Management entities.
Travel
Travel between Alliance offices, attending meetings on behalf of Alliance, and participating in Alliance-sponsored events may be required.
Travel to meet with members, providers, stakeholders, attend court hearings, etc. is required.
Education & Experience
Option 1: Bachelor’s degree in a non‑Human Services field and four (4) years of experience providing care management to individuals with Traumatic Brain Injuries (TBI), Intellectual/Developmental Disabilities (I/DD), Mental Health/Substance Use Disorders (MH/SUD), Severe Mental Illness (SMI), or Physical Health (PH).
Option 2: Bachelor’s degree in a Human Services field and three (3) years of experience providing care management to individuals with TBI, I/DD, MH/SUD, SMI, or PH.
Option 3: Bachelor’s degree in a Human Services field and three (3) years’ experience conducting provider monitoring/investigations or program evaluation activities.
Required Experience
Experience developing or reviewing Care plans, comprehensive assessments, care management interventions, and service engagement activities.
Experience with Medicaid Managed Care.
Experience with Integrated care (behavioral and physical health).
Experience in program/services monitoring, program evaluation.
Preferred Experience
Auditing clinical documentation.
Preferred Certification
Certified Care Manager (CCM).
Knowledge, Skills & Abilities
Knowledge of North Carolina state and federal rules and requirements related to the service continuum in North Carolina.
Knowledge of Tailored Plan, Integrated Care, and Care Management processes and regulatory requirements.
Knowledge of best and promising practices for behavioral & physical health and/or intellectual/developmental disabilities.
Microsoft Excel, Word, PowerPoint, SPSS, and Survey Monkey (or other online survey tool).
Strong clinical skills.
Problem‑solving skills.
Interpersonal skills.
Strong analytical skills.
Problem‑solving and conflict‑resolution skills.
Strong diplomacy skills and discretion.
Highly effective communication skills.
Ability to negotiate and resolve issues with minimal assistance.
Employment Contingent Employment for this position is contingent upon a satisfactory background and MVR (Motor Vehicle Registration) check, which will be performed after acceptance of an offer of employment and prior to the employee's start date.
Salary Range $28.96 - $36.92 / Hourly
Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.
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, holiday, management leave.
Dress flexibility.
Equal Opportunity Employer. This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.
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The External Clinical Quality Analyst I manages the quality review process for provider-led care management programs. Incumbents conduct quality reviews and audits of provider-led care management programs and processes for quality assurance purposes and to support the effective functioning of provider-led care management.
This position is full-time remote and selected candidates must reside in North Carolina. Some travel for onsite meetings to the home office may be required.
Responsibilities Analyze Care Management Documentation and Activities to Ensure Compliance
Review the quality of provider-led Care Management programs by completing administrative reviews coupled with detailed clinical case reviews for alignment with all requirements identified in the NC DHHS Tailored Care Management Provider Manual.
Audit provider-led Care Management policy and procedures, staffing, training, and provision of all Care Management activities including clinical documentation to ensure alignment with program descriptions, workflows, evidence‑based clinical guidelines, NCQA guidelines, CMS guidelines, and regulatory guidelines (when applicable).
Analyze program data to identify trends and develop and implement corrective action plans as appropriate.
Interpret qualitative and quantitative information to document findings and ensure contractual requirements are met.
Identify system and/or operational issues hindering the attainment of quality performance standards as defined by NCQA standards, applicable state and Federal laws and regulations.
Analyze Data and Report on Findings
Provide written feedback to the Senior Director of Network Evaluation, Practice Transformation Team, and Compliance concerning quality concerns pertaining to program performance and compliance risks/trends.
Evaluate Knowledge Gaps of Staff and Coordinate Training
Evaluate knowledge gaps of the provider-led Care Management staff and collaborate with Provider Network, Practice Transformation and Care Management Leadership to coordinate learning and training opportunities for provider-led Care Management entities.
Travel
Travel between Alliance offices, attending meetings on behalf of Alliance, and participating in Alliance-sponsored events may be required.
Travel to meet with members, providers, stakeholders, attend court hearings, etc. is required.
Education & Experience
Option 1: Bachelor’s degree in a non‑Human Services field and four (4) years of experience providing care management to individuals with Traumatic Brain Injuries (TBI), Intellectual/Developmental Disabilities (I/DD), Mental Health/Substance Use Disorders (MH/SUD), Severe Mental Illness (SMI), or Physical Health (PH).
Option 2: Bachelor’s degree in a Human Services field and three (3) years of experience providing care management to individuals with TBI, I/DD, MH/SUD, SMI, or PH.
Option 3: Bachelor’s degree in a Human Services field and three (3) years’ experience conducting provider monitoring/investigations or program evaluation activities.
Required Experience
Experience developing or reviewing Care plans, comprehensive assessments, care management interventions, and service engagement activities.
Experience with Medicaid Managed Care.
Experience with Integrated care (behavioral and physical health).
Experience in program/services monitoring, program evaluation.
Preferred Experience
Auditing clinical documentation.
Preferred Certification
Certified Care Manager (CCM).
Knowledge, Skills & Abilities
Knowledge of North Carolina state and federal rules and requirements related to the service continuum in North Carolina.
Knowledge of Tailored Plan, Integrated Care, and Care Management processes and regulatory requirements.
Knowledge of best and promising practices for behavioral & physical health and/or intellectual/developmental disabilities.
Microsoft Excel, Word, PowerPoint, SPSS, and Survey Monkey (or other online survey tool).
Strong clinical skills.
Problem‑solving skills.
Interpersonal skills.
Strong analytical skills.
Problem‑solving and conflict‑resolution skills.
Strong diplomacy skills and discretion.
Highly effective communication skills.
Ability to negotiate and resolve issues with minimal assistance.
Employment Contingent Employment for this position is contingent upon a satisfactory background and MVR (Motor Vehicle Registration) check, which will be performed after acceptance of an offer of employment and prior to the employee's start date.
Salary Range $28.96 - $36.92 / Hourly
Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.
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, holiday, management leave.
Dress flexibility.
Equal Opportunity Employer. This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.
#J-18808-Ljbffr