Evaluator

• 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

Evaluator jobs in North Carolina

Provider Network Evaluator II – Clinical Quality