Provider Network Evaluator II-Targeted; Remote, North Carolina

Provider Network Evaluator II-Targeted (Full-time Remote, North Carolina based)

Posted on February 25, 2026

Remote in NC – North Carolina, USA

Home Office – 5200 W. Paramount Parkway Ste 200, Morrisville, NC 27560, USA

Mecklenburg Office – 8520 Cliff Cameron Drive Ste 300, Charlotte, NC 28269, USA

Cumberland Office – 711 Executive Place, Fayetteville, NC 28305, USA

Johnston Office – 521 North Brightleaf Blvd, Smithfield, NC 27577, USA

The PNE Targeted Reviewer II holds and maintains clinical licensure and is responsible for conducting focused and targeted reviews that may include health and safety reviews, quality of care issues, intensive incident report reviews, and determines the appropriateness of clinical services delivered by providers in the Alliance network. The PNE Targeted Reviewer II is required to review claims data, clinical documentation, provider contracts, policies, and procedures, conduct provider staff and stakeholder interviews, and review reference and regulatory materials, to identify out of compliance findings, over payments, quality of care and health and safety issues, clinical concerns, and other irregularities.

Due to the varying nature of Targeted Reviews, the PNE II Targeted Reviewer is responsible for the development of review tools specific to the scope of the review.

This position is full-time remote. Selected candidate must reside in North Carolina and within 60-mile radius of any of Alliance Office. Some travel for onsite meetings may be required.

• The PNE Targeted Reviewer II is responsible for conducting health and safety reviews, quality of care issues, intensive incident report reviews, and focused and targeted monitoring of providers and the services provided in the Alliance network
• The PNE Targeted Reviewer II is responsible for reviewing claims data, clinical documentation, provider contracts, policies, and procedures, conducting witness and member interviews, reviewing reference and regulatory materials, and providing technical assistance
• Conduct targeted and focused monitoring to include reviewing allegation(s) related to quality of care, health and safety, incident reports, compliance with service delivery, adherence to Medicaid contract and State funding, provider operation expectations and other concerns that are outside the scope of post-payment reviews and special investigations unit activities
• Utilize clinical knowledge and expertise in the review of clinical documentation to assess and determine if services being provided are clinically appropriate and demonstrate best practice and evidence-based interventions
• Develop targeted and focused monitoring plans based upon referrals, a review of internal documents and supporting materials, the allegations, and any additional identified concerns
• Create and develop review tools specific to the targeted and focused monitoring being undertaken to effectively and accurately assess the allegations and concerns identified in referrals
• Request and/or accurately collect, document, inventory, and store evidence. This includes clinical and medical records, personnel records, policies/procedures, quality management plans, and other needed documents from providers based on the nature of the allegations and type of review.
• Conduct interviews with internal employees, provider employees, former employees, recipients of services, and other individuals.
• Determine if allegations were substantiated and be able to support findings. Identify out of compliance findings, health and safety issues, over payments, and other irregularities
• Record and track all monitoring and audit activities, allegations related to quality of care, and health and safety from referral to final disposition
• Document allegations, internal and external communications, investigative activities, material and document reviews, and findings in a detailed audit/investigation report
• Function as review lead and/or work in collaboration with the PNE Targeted Team to support targeted, focused, health and safety and quality of care monitoring activities

• Diligently research clinical…