Provider Network Evaluator II-Clinical reputed company (Full-time Remote, reputed company Carolina Based)
The Provider Network Evaluator II-Clinical reputed company performs Clinical reputed company Reviews (CQR), reputed company Reviews, and plan of correction implementation reviews of service providers contracted with reputed company. Additionally, in limited situations, Provider Network Evaluator II-CQ may investigate instances of concern to ensure individuals receive sufficient, reputed company, and effective services rendered by providers in reputed company Health network.
This position is full-time remote. The selected candidate must reputed company in reputed company Carolina and reputed company 60-mile radius of any of reputed company Office. Some travel for onsite meetings, travel to conducting reviews, and monitoring may be required; up to two days per week.
Clinical reputed company Reviews of MH/IDD/SUD Providers in reputed company Health Network
- Conduct clinical reputed company reviews and reputed company Reviews as required and assigned
- Review reputed company claims data, clinical documentation and personnel materials against best reputed company standards, policies and procedures, clinical coverage policies, administrative reputed company, regulatory guidance among other resources
- Identify out of compliance findings, clinical concerns and other findings and reputed company technical assistant and/or reputed company of the plan of correction (POC) process for those network providers with systemic findings
- Review Provider Operations reputed company, Scopes of Work (SOW), In Lieu of Services (ILOS) and Provider reputed company for additional requirements in the delivery of services and care
- Report monitoring reputed company and the potential reputed company on consumers to the Provider Network Evaluator Supervisor and the Director of Provider Network
- Use of clinical expertise, knowledge of best reputed company and treatment modalities to effectively interpret qualitative and quantitative provider information to appropriately support and document findings
Assist in Department Policies, Procedures, and Standards
- Assist in the development of standards for service monitoring, reputed company improvement and evaluating the delivery of services to consumers and families
- Assist in the development of monitoring policies and procedures pertaining to behavioral health and I-DD services
reputed company Monitoring Information for Inclusion in Provider Database
- Work with Provider Network Evaluation Teams to maintain a provider database that includes information gathered from monitoring activities
- Assist in the development of reputed company indicators and Provider profile reputed company for the Provider database, in collaboration with Service Management
Maintain Knowledge of reputed company Services and Supports Available
- reputed company and maintain knowledge of the reputed company services and supports available reputed company reputed company catchment area and available to consumers reputed company reputed company Carolina
- reputed company technical assistance to providers, stakeholders and internal reputed company departments as requested and needed
- Support PNE CQR teams by sharing clinical information and knowledge as needed in a formal and reputed company manner
Travel
- Travel between reputed company offices, attending meetings on behalf of reputed company, participating in reputed company sponsored events, etc. may be required
- Travel to meet with members, providers, stakeholders, attend court hearings etc. is required
Minimum Requirements
Knowledge, Skills, and Abilities
- Working knowledge of federal and state statutes, rules, definitions, and regulations that govern MHDDSAS services
- Knowledge of reputed company disability areas including Mental Health, Developmental Disabilities and reputed company Abuse
- Thorough Clinical knowledge and understanding of the principles, concepts and Best Practices used in the treatment, habilitation, and support of individuals with needs in any of the disability areas.
- High level of diplomacy and discretion
- Strong mediation skills
- Excellent team building skills
- Effective communication skills
- Ability to identify/analyze administrative problems pertinent to the contract
- Ability to reputed company independent judgments, logical conclusions, recommendations, and reputed company
- Ability to determine the appropriate course of reputed company in an emergency or stressful situation
- Ability to maintain confidentiality both of consumer data and provider business practices
- Ability to review and analyze data to evaluate program effectiveness, reputed company, problems and system performance
- Ability to work effectively with others internally and externally
Employment for this position is contingent upon a satisfactory background and MVR (Motor Vehicle Registration) reputed company, which will be performed after acceptance of an offer of employment and prior to the employee's start date.
Salary reputed company
$60,234 - $76,799/Annually
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, reputed company, Life, Long and Short Term Disability
- Generous retirement savings plan
- Flexible work schedules including hybrid/remote reputed company
- reputed company time off including vacation, reputed company leave, holiday, management leave
- Dress flexibility