External Clinical Quality Analyst I (Full-time Remote, North Carolina Based)
About The Position
The External Clinical Quality Analyst I manages the quality review process for provider-led care management programs. The role conducts quality reviews and audits of provider-led programs and processes to support quality assurance and effective program functioning. This is a full-time remote position for a candidate residing in North Carolina. Some travel to the home office and other travel for Alliance-related meetings, events, and visits with members, providers, and stakeholders, including court hearings, may be required. The analyst reviews program documentation and activities for compliance with the NC DHHS Tailored Care Management Provider Manual, program workflows, clinical guidelines, NCQA and CMS guidelines, and applicable regulatory requirements. The role analyzes program data, documents findings, identifies performance and compliance risks, recommends or implements corrective actions as appropriate, and communicates concerns to leadership and partner teams. The analyst also evaluates provider-led care management staff knowledge gaps and coordinates learning and training opportunities with relevant teams.
Requirements
- Bachelor’s degree in a non-Human Services field and four years of experience providing care management to individuals with 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 a bachelor’s degree in a Human Services field and three years of such care management experience; OR a bachelor’s degree in a Human Services field and three years of experience conducting provider monitoring/investigations or program evaluation activities.
- Experience developing or reviewing care plans, comprehensive assessments, care management interventions, and service engagement activities.
- Experience in Medicaid Managed Care, integrated care (behavioral and physical health), or program/services monitoring or program evaluation.
- 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 and physical health and/or intellectual/developmental disabilities.
- Proficiency with Microsoft Excel, Word, and PowerPoint, SPSS, and Survey Monkey or another online survey tool.
- Strong clinical, problem-solving, interpersonal, analytical, conflict-resolution, diplomacy, discretion, and communication skills.
- Ability to negotiate and resolve issues with minimal assistance.
- Must reside in North Carolina.
Nice To Haves
- Experience auditing clinical documentation.
- Certified Care Manager (CCM) certification.
Responsibilities
- Review provider-led Care Management programs through administrative reviews and detailed clinical case reviews for alignment with the NC DHHS Tailored Care Management Provider Manual.
- Audit provider-led Care Management policies and procedures, staffing, training, and care management activities, including clinical documentation, for alignment with program descriptions, workflows, evidence-based clinical guidelines, NCQA guidelines, CMS guidelines, and applicable regulatory guidelines.
- Analyze program data to identify trends and develop and implement corrective action plans as appropriate.
- Interpret qualitative and quantitative information, document findings, and ensure contractual requirements are met.
- Identify system and operational issues that hinder attainment of quality performance standards defined by NCQA standards and applicable state and federal laws and regulations.
- Provide written feedback to the Senior Director of Network Evaluation, Practice Transformation Team, and Compliance concerning program quality concerns and compliance risks or trends.
- Evaluate knowledge gaps among provider-led Care Management staff and collaborate with Provider Network, Practice Transformation, and Care Management Leadership to coordinate learning and training opportunities.
- Travel between Alliance offices and attend meetings and Alliance-sponsored events as required.
- Travel to meet with members, providers, and stakeholders and attend court hearings as required.
Benefits
- Medical, dental, vision, life, and long-term disability coverage.
- Generous retirement savings plan.
- Flexible work schedules, including hybrid and remote options.
- Paid time off, including vacation, sick leave, holidays, and management leave.
- Dress flexibility.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
