Provider Network Evaluator II – Clinical Quality

Alliance Health

. Conduct and lead Clinical Quality Reviews, Oversight Reviews, and Plan of Correction implementation reviews of contracted MH/IDD/SUD service providers .

Posted 9/15/2026full-timeRemote • North Carolina • United StatesMid-LevelSenior💰 $61,439 - $78,335 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates advanced clinical expertise in Mental Health, Developmental Disabilities, and Substance Abuse, with a strong focus on regulatory compliance, quality assurance, and effective communication. Capable of leading clinical quality reviews and developing monitoring policies while maintaining confidentiality and ensuring best practices.

Highest-signal resume keywords

Clinical Quality ReviewRegulatory ComplianceLCSW/LCAS/LCMHC/LPA/LMFT LicenseNational Certified Investigator and Inspector Training (NCIT)Evidence-Based Practices

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Documentation ReviewData AnalysisMonitoring Policy DevelopmentService PlanningTreatment Modality Knowledge

Soft Skills

Effective CommunicationTeam BuildingMediation SkillsDiplomacyProblem Solving

Tools & Technologies

Provider Database ManagementStandardized Monitoring ToolsClinical Coverage Policies

Certifications & Qualifications

LCSWLCASLCMHCLPALMFTNational Certified Investigator and Inspector Training (NCIT)

Industry Keywords

Mental HealthDevelopmental DisabilitiesSubstance AbuseMHDDSAS ServicesClinical Guidelines

About the role

Key responsibilities & impact

Conduct and lead Clinical Quality Reviews, Oversight Reviews, and Plan of Correction implementation reviews of contracted MH/IDD/SUD service providers
Lead, guide, support, and peer review team members’ work to ensure inter-rater reliability
Ensure contracted providers apply best practices, clinical guidelines, and regulatory requirements
Review paid claims data, clinical documentation, and personnel materials against applicable standards, policies, procedures, and regulations
Identify and substantiate clinical quality concerns, health and safety risks, service-planning gaps, and regulatory or administrative noncompliance
Distinguish isolated deficiencies from systemic patterns and assess potential impact on members
Provide technical assistance and monitor corrective actions through closure when a Plan of Correction is required
Interpret provider manuals, clinical coverage policies, scopes of work, ILOS, contracts, and governing standards
Report monitoring outcomes and potential impacts to the Provider Network Evaluator Supervisor and Director of Provider Network Evaluation
Apply advanced clinical expertise and treatment-modality knowledge to interpret provider information and document findings
Assist with standardized monitoring tools, guidelines, department policies, procedures, standards, and clinical quality standards
Develop monitoring policies and procedures for behavioral health, substance use, and I-DD services
Maintain provider database information gathered from monitoring activities
Develop quality indicators and provider profile elements in collaboration with Service Management
Maintain knowledge of services and supports available within the Alliance catchment area and North Carolina
Provide technical assistance to providers, stakeholders, and internal Alliance Health departments
Support Provider Network Evaluation teams and external Alliance units by sharing clinical information
Travel between Alliance offices, meet providers and stakeholders, attend meetings, events, and court hearings as required

Requirements

What you’ll need

Master’s degree from an accredited college or university in a Human Services field (such as Psychology, Social Work, etc.)
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
National Certified Investigator and Inspector Training (NCIT) is required; NCIT must be successfully completed within 6 months of hire and meet the 1-year employment requirements as a regulatory investigator/inspector
Working knowledge of federal and state statutes, rules, definitions, and regulations governing MHDDSAS services
Knowledge of evidence-based practices, levels of care, service planning, DSM criteria, and professional communication and writing
Knowledge of Clinical Coverage Policies, Records Management and Documentation Management
Knowledge of Mental Health, Developmental Disabilities, and Substance Abuse disability areas
Thorough clinical knowledge of treatment, habilitation, and support principles, concepts, and best practices
High level of diplomacy and discretion
Strong mediation skills
Excellent team building skills
Effective communication 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 appropriate 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

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