External Clinical Quality Analyst I (Full-time Remote, North Carolina Based)

The External Clinical Quality Analyst I 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.

Analyze Care Management Documentation and Activities to Ensure Compliance

• →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

Analyze Data and Report on Findings

• →Provide written feedback to the Senior Director of Network Evaluation, Practice Transformation Team, and Compliance concerning quality concerns pertaining to program performance, and compliance risks/trends

Evaluate Knowledge Gaps of Staff and Coordinate Training

• →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

 Travel

• →Travel between Alliance offices, attending meetings on behalf of Alliance, participating in Alliance sponsored events, etc. may be required
• →Travel to meet with members, providers, stakeholders, attend court hearings etc. is required

Bachelor’s degree in a non-Human Services field and four (4) years of experience with 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

Bachelor’s degree in a Human Services field and three (3) years of experience with 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

Bachelor’s degree in a Human Services field and three (3) years experience conducting provider monitoring/investigations or program evaluation activities.

Experience developing or reviewing Care plans, comprehensive assessments, care management interventions, and service engagement activities

Medicaid Managed Care 

Integrated care (behavioral and physical health) or

Program/services monitoring, program evaluation

Auditing Clinical documentation 

Certified Care Manager (CCM)

• 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
• Problem solving skills
• Interpersonal Skills
• Strong Analytical skills
• Problem solving and conflict resolution skills
• Strong diplomacy skills and discretion
• Highly effective communication skills
• Ability to negotiate and resolve issues with minimal assistance

$29.54 - $37.66/Hourly