Provider Network Evaluator I-Targeted Monitoring (Full-time Remote, North Caroli

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 materi