The PNE Targeted Reviewer II holds and maintains clinical licensure and is responsible for conducting focused and targeted reviews that may include health and safety reviews, quality of care issues, intensive incident report reviews, the appropriateness of clinical services delivered by providers in the Alliance network. The PNE Targeted Reviewer II is required to review claims data, clinical documentation, provider contracts, policies, and procedures, conduct provider staff and stakeholder interviews, review reference and regulatory materials, to identify out of compliance findings, overpayments, quality of care and health and safety issues, clinical concerns, and other irregularities. Due to the varying nature of Targeted Reviews, the PNE II Targeted Reviewer is responsible for the development of review tools specific to the scope of the review.
This position is full-time remote. Selected candidate must reside in North Carolina. Some Travel for onsite meetings to the Home office (Morrisville, NC) or Mecklenburg (charlotte, NC) may be required.
Responsibilities & Duties
The PNE Targeted Reviewer II is responsible for conducting health and safety reviews, quality of care issues, intensive incident report reviews, and focused and targeted monitoring of providers and the services provided in the Alliance network
The PNE Targeted Reviewer II is responsible for reviewing claims data, clinical documentation, provider contracts, policies, and procedures, conducting witness and member interviews, reviewing reference and regulatory materials, and providing technical assistance
Conduct targeted and focused monitoring to include reviewing allegation(s) related to quality of care, health and safety, incident reports, compliance with service delivery, adherence to Medicaid contract and State funding, provider operation expectations and other concerns that are outside the scope of post-payment reviews and special investigations unit activities
Utilize clinical knowledge and expertise in the review of clinical documentation to assess and determine if services being provided are clinically appropriate and demonstrate best practice and evidence-based interventions
Develop targeted and focused monitoring plans based upon referrals, a review of internal documents and supporting materials, the allegations, and any additional identified concerns
Create and develop review tools specific to the targeted and focused monitoring being undertaken to effectively and accurately assess the allegations and concerns identified in referrals
Request and/or accurately collect, document, inventory, and store evidence. This includes clinical and medical records, personnel records, policies/procedures, quality management plans, and other needed documents from providers based on the nature of the allegations and type of review.
Conduct interviews with internal employees, provider employees, former employees, recipients of services, and other individuals.
Determine if allegations were substantiated and be able to support findings. Identify out of compliance findings, health and safety issues, overpayments, and other irregularities
Record and track all monitoring and audit activities, allegations related to quality of care, and health and safety from referral to final disposition
Document allegations, internal and external communications, investigative activities, material and document reviews, and findings in a detailed audit/investigation report
Function as review lead and/or work in collaboration with the PNE Targeted Team to support targeted, focused, health and safety and quality of care monitoring activities
Regulatory Review/ Research
Diligently research clinical policies, administrative code, federal/state laws to assess for quality of care and health, safety issues and non-compliance
Review and research scopes of work, in lieu service definitions and service lines to assess implementation and adherence
Provide clinical guidance to non-clinical staff on Medicaid Clinical Coverage Policies and State Service Definitions and by participating in ad hoc meetings related to clinical regulatory matters
Present audit/investigation findings and make disposition recommendations using independent judgment to the Senior Director of Provider Network Evaluation, PNE Targeted Team Supervisor, Alliance Compliance Committee and when necessary, to Alliance general counsel
Present case status updates in individual supervision sessions, unit team meetings, and as required or requested
Act as a resource within the targeted team to assist and support the review of clinical materials and documentation and the appropriateness of services being provide
Conduct and participate in Targeted/Focused Review Planning meetings with the PNE Targeted Team
Interpret and convey highly technical information to others
Data Analytics and Synthesis
Identify other data sources and materials to review during investigations based on the allegation(s)
Review data from a variety of sources, including but not limited to claims, authorizations, credentialing/enrollment, Jiva, grievances, prior audits/investigations, incident reports, and policies/procedures, to inform decision making, next steps and monitoring recommendations
Utilize various MicroStrategy reports during the pre-investigation and the investigation process
Review claims data and authorizations to determine if there are irregularities or areas of concerns to be further pursued
Identify areas of concerns and draw conclusions based on materials reviewed
Provider Action and Follow-Up
Document findings on Improper Payment Charts, Statements of Deficiency, and provide feedback and technical assistance to providers as needed/requested
Follow up on provider corrective action(s) through the POC implementation and probation process, when applicable
Provide technical assistance (TA) when necessary to assist the provider in addressing quality of care, health, safety, and out of compliance issues
Prepare for and participate in provider appeal process/reconsideration, and/or court hearings to explain and defend audit/investigation findings
Recommend revisions to Alliance Health procedures and policies
Consult with the Corporate Compliance Unit when potential internal compliance issues are identified
Recognize when fraud, waste and abuse are present and a referral to the Special Investigations unit is necessary
Perform other job-related duties as assigned by the Supervisor
Knowledge, Skills, & Abilities
Knowledge of the state and federal Medicaid laws, state and federal laws, regulations, policies, rules, guidelines, service limitations, and various Medicaid programs.
Knowledge and proficiency in claims adjudication standards & procedures.
Knowledge of investigative methods and procedures.
Knowledge of the Alliance Health service benefit plans and network providers.
A general understanding of all major MCO functions as it relates to prior authorization, utilization reviews, grievance management, provider credentialing and monitoring.
Skill in using Microsoft Office products (such as Word, Excel, Outlook, etc.).
Strong verbal and written communication skills. Ability to write clear, accurate and concise rationale in support of findings.
Analytical skills and ability to make deductions; logical and sequential thinker.
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 and confidentiality required handling information that is considered personal and confidential.
Ability to manage time, prioritize work, and use problem-solving approaches.
Education & Experience
Master’s degree in human services/social sciences, from an accredited College/University and five (5) years post-Master’s experience in healthcare compliance, monitoring, policy development, auditing, quality improvement/quality assurance, regulatory management, investigations, accreditation, analytics, government/public administration and/or auditing.
Must have a current, active NC license as a LCSW, LCMHC, LPA, LMFT, or LCAS.
The National Certified Investigator and Inspector Training (NCIT) is preferred, but not required. NCIT 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 & procedures preferred.
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 and Short Term Disability
Generous retirement savings plan
Flexible work schedules including hybrid/remote options
Paid time off including vacation, sick leave, holiday, management leave