Provider Network Evaluator -HCBS; Remote, Mecklenburg

The Provider Network Evaluator I-HCBS works as part of the Provider Network Evaluation (PNE) Department on the Home and Community Based Services (HCBS) team. Home and Community Based Services provide opportunities for Medicaid beneficiaries to receive services in their own home or in community settings instead of institutional settings. The Home and Community Based Services team is responsible for conducting reviews of Unlicensed Alternatives to Family Living placements for Alliance members, and reviews of member self-directed services (Employee of Record) as described in CCP8P, Attachment H, and service delivery under 1915(i) waiver.

The PNE I-HCBS will also be involved in ensuring that HCBS final rule requirements are followed, to include ensuring validation of agency self-assessments and that member surveys are remediated when follow-up is required.

The PNE I-HCBS is a remote position; however, travel is required at least weekly to conduct on-site reviews and monitoring. Travel to Alliance Health office in Mecklenburg County is required as needed.

Validate and Approve TBI, Innovation Waiver, 1915(i), and LTCS Sites and Services

• Develop and maintain knowledge of HCBS Final Rule, HCBS Standard Operating Procedure, 1915(i) Waiver, Clinical Coverage Policy, NC Administrative Code, Records Management and Documentation Manual and other regulatory resources and guidelines to ensure standards and requirements are in compliance
• Review and validate service site documentation for TBI, Innovation Waiver, 1915(i), and LTCS programs; confirm compliance with regulatory standards to authorize member access to new or existing service locations
• Perform HCBS reviews as required and within the required time frames
• Review provider policies and procedures for compliance with CMS mandated HCBS standards
• Review and manage HCBS portal to ensure portal entries are reviewed and accepted prior to service initiation and move in
• Collaborate with other MCOs when a member is transferred into the Alliance catchment area or transferred out of the Alliance catchment area
• Work with providers to ensure out of compliance findings are remedied either by providing technical assistance and/or through a plan of correction
• Work with I/DD Care Coordination, Provider Network Development and agency providers to ensure sites are validated and in compliance
• Remediate issues and concerns that are identified by the State with MIE surveys through documentation review, technical assistance with providers and other stakeholders, and collaboration with I/DD Care Coordinators
• Provide reports and updates on outcomes of reviews of HCBS and the potential impact on consumers involved to the Provider Network Evaluator Supervisor and/or the Director of Network Evaluation

Review and Monitor Unlicensed Alternative to Family Living

• Follow UAFL monitoring desk procedures for Unlicensed Alternative to Family Living placements for annual reviews and initial reviews
• Ensure the site is contracted and provider is credentialed
• Review UAFLs on annually and conduct initial site reviews as required using the UAFL tool with special attention to member health, safety and protection of client rights
• Immediately address health, safety and quality of care issues for Alliance Health members when identified
  
  When out of compliance findings are identified, work with the provider to remedy via technical assistance and/or Plan of Correction
• Maintain and update service sites and member locations as necessary

Review and Monitor Individual and Family Directed Services

• Review self-directed services (Employer of Record) on an annual basis as required
• Provide technical assistance when required to ensure compliance with CCP8-P, Attachment H and other mandated…