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Alliance HealthPosted 10/21/2026full-timeRemote • North Carolina • United StatesMid-LevelSenior💰 $30 - $38 per hourWebsite
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in healthcare compliance, provider monitoring, and auditing, with a strong understanding of Medicaid laws and regulations. Proficient in conducting investigations, analyzing data, and presenting findings to stakeholders.
Highest-signal resume keywords
Healthcare ComplianceProvider MonitoringAuditingMedicaid LawsClaims Adjudication
About the role
Key responsibilities & impact- Conduct targeted and focused monitoring of quality of care, 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, allegations, and identified concerns
- Create review tools specific to each targeted or focused monitoring activity
- Request, collect, document, inventory, and store clinical records, medical records, personnel records, policies, procedures, quality management plans, and other evidence
- Conduct interviews with internal employees, provider employees, former employees, service recipients, and other individuals
- Identify noncompliance findings, health and safety issues, overpayments, and irregularities; determine whether allegations are substantiated
- Record and track monitoring and audit activities from referral through final disposition
- Document allegations, communications, investigative activities, reviews, and findings in detailed audit/investigation reports
- Lead reviews or collaborate with the PNE Targeted Team
- Research clinical coverage policies, administrative codes, bulletins, scopes of work, service manuals, provider operations manuals, and federal/state laws
- Present review findings and disposition recommendations to leadership, compliance committees, and general counsel when necessary
- Provide case status updates and present oral or written reports to stakeholders
- Interpret and convey highly technical information
- Review claims, authorizations, credentialing/enrollment, Jiva, grievances, prior audits/investigations, incident reports, and policies/procedures
- Utilize MicroStrategy reports during pre-investigation and investigation processes
- Review claims data and authorizations to identify irregularities and concerns
- Prepare improper payment charts and statements of deficiency; provide provider feedback and technical assistance
- Follow up on corrective actions and participate in provider appeals, reconsiderations, and court hearings
- Recommend revisions to Alliance Health procedures and policies
- Consult Corporate Compliance and refer suspected fraud, waste, and abuse to Special Investigations
- Perform other duties assigned by the Supervisor
Requirements
What you’ll need- Bachelor’s degree in human services or social sciences from an accredited College/University
- Five (5) years of post-degree experience in healthcare compliance, provider monitoring, policy development, auditing, investigations, accreditation, or equivalent combination of related training and experience
- NCIT preferred but not required; must be successfully completed within 6 months of hire
- Health care industry and/or Medicare/Medicaid/Behavioral Health knowledge preferred
- Knowledge and proficiency in claims adjudication standards and procedures
- Knowledge of state and federal Medicaid laws, regulations, policies, rules, guidelines, service limitations, and Medicaid programs
- Knowledge of Alliance Health service benefit plans and network providers
- General understanding of MCO functions involving prior authorization, utilization reviews, grievance management, provider credentialing, and monitoring
- Proficiency using Microsoft Office products, including Word, Excel, and Outlook
- Strong verbal and written communication skills
- Ability to write clear, accurate, and concise rationale supporting findings
- Analytical, deductive, logical, and sequential thinking skills
- Ability to identify resources, gather evidence, analyze raw data, and generate reports
- Ability to interpret contractual agreements, business-oriented statistics, medical/administrative services, and records
- High degree of integrity, discretion, and confidentiality
- Ability to manage time, prioritize work, and use problem-solving approaches
- Knowledge of investigative methods and procedures
Benefits
Comp & perks- 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
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Policy DevelopmentInvestigative MethodsData AnalysisReport GenerationQuality Management PlansIncident ReportingMonitoring PlansClinical Records ManagementTechnical WritingEvidence Gathering
Soft Skills
Strong Communication SkillsAnalytical ThinkingProblem-SolvingTime ManagementIntegrity and Confidentiality
Tools & Technologies
Microsoft OfficeMicroStrategyJiva
Certifications & Qualifications
NCIT (Preferred)
Industry Keywords
MedicaidBehavioral HealthAccreditationMCO FunctionsProvider CredentialingGrievance ManagementService DeliveryHealth and Safety ComplianceFederal/State RegulationsProvider Operations