The PNE II possesses and maintains clinical licensure and is responsible for conducting monitoring activities to ensure Medicaid beneficiaries are receiving MH/IDD/SUD services as required. The monitoring activities include post payment reviews and clinical quality reviews of those providers in the Alliance Health network. There may be limited instances when the PNE II will assist with targeted reviews and Unlicensed AFL reviews.

This position will allow the successful candidate to work a primarily remote schedule. However, travel is required to conduct on-site reviews and monitoring, at least two days per week. 

Responsibilities and Duties

Monitoring of MH/IDD/SUD Providers in the Alliance Health Network

Conduct provider monitoring, post-payment reviews, and clinical quality reviews as required Review paid claims data, clinical documentation and personnel materials against best practice standards, policies and procedures, clinical coverage policies, administrative code, regulatory guidance among other resources Identify out of compliance findings, clinical concerns and other findings and provide technical assistant and/or oversight of the plan of correction (POC) process for those network providers with systemic findings Review Provider Operations Manual, Scopes of Work, In Lieu of Services and Provider contracts for additional requirements in the delivery of services and care Report monitoring outcomes and the potential impact on consumers involved to the Provider Network Evaluator Supervisor and the Director of Provider Network Using clinical expertise, effectively interpret qualitative and quantitative provider information to appropriately support and document findings

Assist in Department Policies, Procedures, and Standards

Assist in the development of standards for service monitoring, quality improvement and evaluating the delivery of services to consumers and families Assist in the development of monitoring policies and procedures pertaining to behavioral health and I-DD services

Provide Monitoring Information for Inclusion in Provider Database

Work with Provider Network Team to maintain a provider database that includes information gathered from monitoring activities Assist in the development of quality indicators and Provider profile elements for the Provider database, in collaboration with Service Management 

Maintain Knowledge of Current Services and Supports Available

Acquire and maintain knowledge of the current services and supports available within the Alliance catchment area and available to consumers within North Carolina Provide technical assistance to providers, stakeholders and internal Alliance Health departments as requested and needed

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

Minimum Requirements

Master’s degree from an accredited college or university in a Human Services field (such as Psychology, Social Work, etc.) and a minimum of three (3) years post master’s degree progressive experience in the field of mental health, developmental disabilities, or substance abuse.  Must maintain a valid driver’s license and a good driving record. 

Must have full, current, and active NC license as an LCSW, LCAS, LCMHC, LPA, or LMFT.

The National Certified Investigator and Inspector Training (NCIT) is preferred, but not required. NCIT must be successfully completed within 6-months of hire.

Knowledge, Skills, and Abilities

Working knowledge of federal and state statutes, rules, definitions, and regulations that govern MHDDSAS services Knowledge of all disability areas including Mental Health, Developmental Disabilities and Substance Abuse Thorough Clinical knowledge and understanding of the principles, concepts and Best Practices used in the treatment, habilitation, and support of individuals with needs in any of the disability areas. High level of diplomacy and discretion Strong mediation skills Excellent team building skills Effective communication skills Ability to identify/analyze administrative problems pertinent to the contract  Ability to make independent judgments, logical conclusions, recommendations, and decisions Ability to determine the appropriate course of action in an emergency or stressful situation Ability to maintain confidentiality both 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 others internally and externally

Salary Range

$58,480 - $74,562/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:   

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