Provider Network Evaluator I-Targeted Monitoring (Full-time Remote, North Carolina Based)

Alliance Health•Fayetteville, NC

10d•$30 - $38•Remote

About The Position

The Provider Network Evaluator I-Targeted Monitoring conducts focused and targeted reviews of providers in the Alliance network. Reviews may cover health and safety, quality of care, incident reports, clinical services, service delivery, compliance with Medicaid contracts and state funding requirements, provider operations, and other concerns outside the scope of post-payment reviews and special investigations. The role reviews claims data, clinical documentation, provider contracts, policies, procedures, and regulatory materials; interviews provider staff and stakeholders; and identifies noncompliance, overpayments, quality-of-care concerns, health and safety issues, and other irregularities. The evaluator develops review tools tailored to the scope of each review and documents activities and findings. This is a remote position based in North Carolina, with travel required as needed for on-site reviews, monitoring, and training. The evaluator may lead reviews or collaborate with the PNE Targeted Team, present findings and recommendations to internal committees and stakeholders, support provider corrective actions and appeals, and provide technical assistance. The position also researches applicable clinical, administrative, contractual, state, and federal requirements and analyzes data from multiple sources to inform review decisions. Candidates must have a bachelor's degree in human services or social sciences and five years of post-degree experience in healthcare compliance, provider monitoring, policy development, auditing, investigations, accreditation, or an equivalent combination of related training and experience. NCIT is preferred but not required and must be completed within six months of hire if not already completed. The salary range is $29.54–$37.66 per hour, with exact compensation based on education, experience, market data, and internal equity.

Requirements

Bachelor's degree in human services or social sciences from an accredited college or university.
Five years of post-degree experience in healthcare compliance, provider monitoring, policy development, auditing, investigations, or accreditation, or an equivalent combination of related training and experience.
Knowledge of state and federal Medicaid laws and other state and federal laws, regulations, policies, rules, guidelines, service limitations, and Medicaid programs.
Knowledge and proficiency in claims adjudication standards and procedures.
Knowledge of Alliance Health service benefit plans and network providers.
General understanding of managed care organization functions related to prior authorization, utilization reviews, grievance management, provider credentialing, and monitoring.
Proficiency with Microsoft Office products such as Word, Excel, and Outlook.
Strong verbal and written communication skills, including the ability to write clear, accurate, concise rationales supporting findings.
Analytical skills, sound deduction, and logical, sequential thinking.
Ability to identify resources, gather evidence, analyze raw data, and generate reports.
Ability to interpret contractual agreements, business-oriented statistics, and medical or administrative services and records.
High integrity, discretion, and confidentiality when handling personal and confidential information.
Ability to manage time, prioritize work, and use problem-solving approaches.
Knowledge of investigative methods and procedures.
Ability to travel as needed for on-site reviews, monitoring, and training.
If not already completed, successfully complete NCIT within six months of hire.

Nice To Haves

National Certified Investigator and Inspector Training (NCIT); preferred but not required.
Healthcare industry and/or Medicare, Medicaid, or behavioral health knowledge.
Knowledge and proficiency in claims adjudication standards and procedures.

Responsibilities

Conduct targeted and focused reviews, including reviews of quality-of-care allegations, health and safety, incident reports, service delivery, Medicaid contract and state funding compliance, provider operations, and other concerns.
Develop monitoring plans based on referrals, internal documents, supporting materials, allegations, and additional concerns.
Create review tools tailored to each targeted or focused monitoring activity.
Request or collect, document, inventory, and store evidence, including clinical and medical records, personnel records, policies and procedures, and quality management plans.
Interview internal employees, current and former provider employees, service recipients, and other individuals.
Identify and substantiate compliance findings, health and safety issues, overpayments, and other irregularities, supporting findings with evidence.
Track monitoring and audit activities and allegations from referral through final disposition.
Document allegations, communications, investigative activities, records reviewed, and findings in detailed audit or investigation reports.
Lead reviews or collaborate with the PNE Targeted Team on targeted, focused, health and safety, and quality-of-care monitoring.
Research clinical coverage policies, administrative codes, bulletins, scopes of work, service manuals, provider operations manuals, and federal and state requirements.
Review scopes of work, in-lieu-of-service definitions, and service lines to assess implementation and adherence.
Present review findings and disposition recommendations using independent judgment to designated leaders, committees, and legal counsel when necessary.
Provide case status updates and present information orally or in writing to supervisors, teams, compliance groups, and other stakeholders.
Participate in review-planning meetings and interpret technical information for others.
Analyze data from claims, authorizations, credentialing and enrollment, Jiva, grievances, prior audits and investigations, incident reports, and policies and procedures.
Use MicroStrategy reports during pre-investigation and investigation activities; review claims and authorization data for irregularities or concerns.
Identify additional data sources, areas of concern, and conclusions based on reviewed materials.
Prepare improper payment charts and statements of deficiency, and provide provider feedback and technical assistance as needed.
Follow up on provider corrective actions through plan-of-correction implementation and probation, as applicable.
Prepare for and participate in provider appeals, reconsideration processes, and court hearings to explain and defend findings.
Recommend revisions to Alliance Health procedures and policies.
Consult Corporate Compliance about potential internal compliance issues and refer suspected fraud, waste, or abuse to the Special Investigations unit when appropriate.
Perform other job-related duties assigned by the Supervisor.