Provider Network Evaluator II-Targeted; Remote, North Carolina

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.

Targeted/Focused Reviews

• 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

Regulatory Review/ Research

• Diligently research clinical policies, administrative code, federal/state laws to assess for quality of care and health, safety issues and non-compliance
• Review and research scopes of work, in lieu service definitions and service lines to assess implementation and adherence
• Provide clinical guidance to non-clinical staff on Medicaid Clinical Coverage Policies and State Service Definitions and by participating in ad hoc meetings related to clinical regulatory matters

Case consultation/presentations

• Present audit/investigation findings and make disposition recommendations using independent judgment to the Senior Director of Provider Network Evaluation, PNE Targeted Team Supervisor, Alliance Compliance Committee and when necessary, to Alliance general counsel
• Present case status updates in individual supervision sessions, unit team meetings, and as required or requested
• Act as a resource within the targeted team to assist and support the review of clinical materials and documentation and the appropriateness of services being provide
• Conduct and participate in Targeted/Focused Review Planning meetings with the PNE Targeted Team
• Interpret and convey highly technical information to others

Data Analytics and Synthesis

• Identify other data sources and materials to review during investigations based on the…