Provider Network Evaluator I-Targeted Monitoring (Full-time Remote, North Carolina Based)

The PNE Targeted Reviewer I 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 I 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 I Targeted Reviewer is responsible for the development of review tools specific to the scope of the review.

The PNE I-Targeted is a remote position; however, travel is required on a as needed basis to conduct on-site reviews, monitoring, and training. Responsibilities And Duties Targeted/Focused Reviews

• 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
• 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 so as 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
• Identify out of compliance findings, health and safety issues, overpayments, and other irregularities. Determine if allegations were substantiated and be able to support findings
• 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 coverage policies, administrative code, bulletins, scopes of work, service manuals, provider operations manual, federal/state laws to assess for quality of care, health, safety issues and non-compliance with standards and contractual obligations
• Review and research scopes of work, in lieu service definitions and service lines to assess implementation and adherence

Case consultation/presentations

• Present focused and targeted review 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, Corporate Compliance, meetings when designated by the team supervisor, and presentations to other Alliance stakeholders as requested or required. These can be both oral presentations and/or in written reports
• Conduct and participate in Targeted and Focused monitoring planning meetings with the PNE Targeted Team
• Interpret and convey highly technical information to others

Data Analytics and Synthesis

• 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…