- 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
- Provide written feedback to the Senior Director of Network Evaluaiton, Practice Transformation Team, and Compliance concerning quality concerns pertaining to program performance, and compliance risks/trends
- 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
- 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
- Strong verbal and written communication skills. Ability to write clear, accurate and concise rationale in support of findings.
- Ability to interpret contractual agreements, business-oriented statistics, medical/administrative services and records.
- Analytical skills and ability to make deductions; logical and sequential thinker.
- Problem solving and conflict resolution skills
- High degree of integrity and confidentiality required handling information that is considered personal and confidential.
- Highly effective communication skills
- Ability to manage time, prioritize work, and use problem-solving approaches
- 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
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External Clinical Quality Analyst II - Charlotte, United States - Alliance
Description
The External Clinical Quality Analyst II 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.Selected candidate must reside in North Carolina and will be required to travel within the communities Alliance serves at least 3 days per week.
Responsibilities & Duties
Analyze Care Management documentation and activities to ensure compliance
Education & Experience
Master's degree in Health, Psychology, Sociology, Social Work, or another relevant Human Services field from an accredited college/university with a North Carolina Clinical license (LCSW, LCMHC, LMFT, LPA) and three (3) years of experience 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
Graduation from an accredited school of nursing with a Registered Nurse (RN) license and three (3) years of experience 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)
(3) years of experience providing care management to individuals in the following populations: Mental Health/Substance Use Disorders (MH/SUD), Severe Mental Illness (SMI), Intellectual/Developmental Disabilities (I/DD), Traumatic Brain Injuries (TBI), or Physical Health (PH)
Required Experience
Experience with Care plans, comprehensive assessments, care management interventions, and service engagement activities, or
Medicaid Managed Care, or
Integrated care (behavioral and physical health), or
Program/services monitoring, program evaluation
Special Requirement
Current, active, unrestricted NC clinical license such as RN, LCSW, LMHC, or LMFT to practice as a health professional within the scope of licensure in the state of North Carolina.
Preferred Experience
Auditing Clinical documentation
Preferred Certification
Certified Care Manager (CCM)
Knowledge, Skills, & Abilities
$66,240 - $84,456/Annually
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:
