Alliance Health
External Clinical Quality Analyst I (Full-time Remote, North Carolina Based)
Alliance Health, Morrisville, North Carolina, United States, 27560
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 fulltime remote. Selected candidate must reside in North Carolina. Some travel for onsite meetings to the Home office may be required.
Responsibilities & Duties Analyze Care Management Documentation and Activities to Ensure Compliance
Review the quality of provider-led Care Management programs by completing administrative reviews is 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 to develop and implement corrective action plans as appropriate
Interpret qualitative and quantitative information to appropriately 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, participating in Alliance sponsored events, etc. may be required
Travel to meet with members, providers, stakeholders, attend court hearings etc. is required
Minimum Requirements Education & Experience Bachelor’s degree in a non-Human Services field and four (4) years of experience with providing care management to individuals in the following populations: Traumatic Brain Injuries (TBI), Intellectual/Developmental Disabilities (I/DD), Mental Health/Substance Use Disorders (MH/SUD), Severe Mental Illness (SMI), or Physical Health (PH)
OR
Bachelor’s degree in a Human Services field and three (3) years of experience with providing care management to individuals in the following populations: Traumatic Brain Injuries (TBI), Intellectual/Developmental Disabilities (I/DD), Mental Health/Substance Use Disorders (MH/SUD), Severe Mental Illness (SMI), or Physical Health (PH)
OR
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
Medicaid Managed Care
Integrated care (behavioral and physical health) or
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 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.
An excellent fringe benefit package accompanies the salary, which includes:
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
Education Preferred
Bachelors or better in Human Services
Bachelors or better in General Studies
Skills
Analysis
Communication
Diplomacy
Microsoft Office
Problem Solving
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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This position is fulltime remote. Selected candidate must reside in North Carolina. Some travel for onsite meetings to the Home office may be required.
Responsibilities & Duties Analyze Care Management Documentation and Activities to Ensure Compliance
Review the quality of provider-led Care Management programs by completing administrative reviews is 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 to develop and implement corrective action plans as appropriate
Interpret qualitative and quantitative information to appropriately 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, participating in Alliance sponsored events, etc. may be required
Travel to meet with members, providers, stakeholders, attend court hearings etc. is required
Minimum Requirements Education & Experience Bachelor’s degree in a non-Human Services field and four (4) years of experience with providing care management to individuals in the following populations: Traumatic Brain Injuries (TBI), Intellectual/Developmental Disabilities (I/DD), Mental Health/Substance Use Disorders (MH/SUD), Severe Mental Illness (SMI), or Physical Health (PH)
OR
Bachelor’s degree in a Human Services field and three (3) years of experience with providing care management to individuals in the following populations: Traumatic Brain Injuries (TBI), Intellectual/Developmental Disabilities (I/DD), Mental Health/Substance Use Disorders (MH/SUD), Severe Mental Illness (SMI), or Physical Health (PH)
OR
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
Medicaid Managed Care
Integrated care (behavioral and physical health) or
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 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.
An excellent fringe benefit package accompanies the salary, which includes:
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
Education Preferred
Bachelors or better in Human Services
Bachelors or better in General Studies
Skills
Analysis
Communication
Diplomacy
Microsoft Office
Problem Solving
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