Provider Network Evaluator I-HCBS (Full-time Remote, Wake County North Carolina Based)

Alliance Health•Smithfield, NC

4d•$26 - $33•Remote

About The Position

The Provider Network Evaluator I-HCBS works in the Provider Network Evaluation Department on the Home and Community Based Services (HCBS) team. The team reviews Unlicensed Alternatives to Family Living placements for Alliance members and member self-directed services (Employee of Record), as well as service delivery under the 1915(i) waiver. The role also helps ensure compliance with HCBS Final Rule requirements, including validation of agency self-assessments and remediation of member surveys when follow-up is required. This is a remote position based in Wake County, North Carolina, with travel required at least weekly for on-site reviews and monitoring. Travel to the Alliance Health office in Wake County is required as needed. The role reviews and validates service locations and documentation, monitors providers and services, supports corrective action when compliance concerns arise, maintains databases and records, and collaborates with providers, care coordination teams, other MCOs, and stakeholders. In limited instances, the evaluator may participate in investigations and focused reviews involving concerns about quality of care, health, and safety.

Requirements

Bachelor’s degree in a human service field, such as Psychology or Social Work.
At least five years of progressive experience in I/DD or TBI.
Strong knowledge of I/DD and TBI services.
Maintain a valid driver’s license and a good driving record.
Complete and pass the National Certified Investigator and Inspector Training (NCIT) course within six months of hire and meet the one-year employment requirement as a regulatory investigator/inspector.
Working knowledge of federal and state statutes, rules, definitions, and regulations governing MHDDSAS services.
Knowledge of disability areas including Mental Health, Developmental Disabilities, and Substance Abuse.
Knowledge and understanding of principles, concepts, and best practices used in the treatment, habilitation, and support of individuals with needs in any disability area.
High level of diplomacy and discretion; strong mediation, team-building, and communication skills.
Microsoft Office skills.
Ability to identify and analyze administrative problems pertinent to the contract.
Ability to make independent judgments, logical conclusions, recommendations, and decisions.
Ability to determine an appropriate course of action in emergency or stressful situations.
Ability to maintain confidentiality of consumer data and provider business practices.
Ability to review and analyze data to evaluate program effectiveness, progress, problems, and system performance.
Ability to work effectively with internal and external parties.

Nice To Haves

Experience with Home and Community Based Services (HCBS) is highly desired.

Responsibilities

Develop and maintain knowledge of the 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.
Review and validate service-site documentation for TBI, Innovation Waiver, 1915(i), and LTCS programs to confirm regulatory compliance and authorize access to new or existing service locations.
Perform HCBS reviews within required timeframes and review provider policies and procedures for compliance with CMS-mandated HCBS standards.
Review and manage the HCBS portal, ensuring entries are reviewed and accepted before service initiation and move-in.
Collaborate with other MCOs when members transfer into or out of the Alliance catchment area.
Work with providers to remedy noncompliance through technical assistance and/or plans of correction.
Coordinate with I/DD Care Coordination, Provider Network Development, and agency providers to validate sites and ensure compliance.
Remediate issues identified by the State through MIE surveys using documentation review, technical assistance, and collaboration with providers, stakeholders, and I/DD Care Coordinators.
Provide reports and updates about HCBS review outcomes and potential effects on consumers to the Provider Network Evaluator Supervisor and/or Director of Network Evaluation.
Conduct annual and initial reviews of Unlicensed Alternative to Family Living placements according to monitoring desk procedures and the UAFL tool.
Ensure UAFL sites are contracted and providers are credentialed; pay particular attention to member health, safety, and client rights during reviews.
Immediately address identified health, safety, and quality-of-care issues affecting Alliance Health members.
Maintain and update service sites and member locations as needed.
Review Employer of Record self-directed services annually and provide technical assistance to support compliance with CCP8-P, Attachment H, and other applicable requirements.
Work with providers to correct noncompliance in individual and family-directed services through technical assistance and/or plans of correction.
Maintain the EOR spreadsheet and required monitoring folders.
Assist with developing and maintaining standards for HCBS and unlicensed AFL sites, Individual and Family Directed Services, quality improvement, and service-delivery evaluation.
Assist in developing monitoring policies and procedures, site validation processes, and MIE survey processes and procedures.
Maintain current databases of HCBS sites requiring monitoring and unlicensed AFL sites requiring annual reviews.
Coordinate with I/DD care coordination to update databases when sites begin or cease serving members, and help ensure database accuracy.
Track and reconcile discrepancies and errors in State-required reports to ensure sites are validated and services are not disrupted.
Track I/DD Care Coordination HCBS assessments and reviews and communicate discrepancies as needed.
Acquire and maintain knowledge of services and supports available in the catchment area and throughout North Carolina, applicable regulations, rules, and member-service requirements.
Participate in investigations and focused reviews in limited instances when quality-of-care, health, or safety concerns arise.
Travel between Alliance offices and to review sites; meet with members, providers, and stakeholders; attend meetings, Alliance-sponsored events, and court hearings as required.