Remote Document Review Jobs in Raleigh, NC (NOW HIRING)

Provider Network Evaluator I (PNE I) is a QP level professional that works as part of the Provider Network Evaluation Department. The department has the responsibility for ensuring that providers are properly delivering services to Alliance members and their families and ensures any out of compliance findings are addressed in a timely manner.

The PNE I-HCBS position will be assigned to the Home and Community Based Services (HCBS) team. This team is responsible for conducting reviews of Unlicensed Alternatives to Family Living placements for Alliance members and reviews of member self-directed services (Employee of Record) as described in CCP8P, Attachment H. The PNE I will also be involved in ensuring that HCBS final rule requirements are followed, to include ensuring validation of agency self-assessments and that member surveys are remediated when follow-up is required.

We are currently seeking to fill two openings; one in the Mecklenburg County area and another in Wake County area. This position is full-time remote but does require travel to conduct on-site reviews and monitoring. The selected candidate must reside in North Carolina.

Responsibilities & Duties

Validate and Approve TBI, Innovation Waiver, 1915(i), and LTCS Sites and Services

Review and validate service site documentation for TBI, Innovation Waiver, 1915(i), and LTCS programs; confirm compliance with regulatory standards to authorize member access to new or existing service locations

Perform HCBS reviews as required and within the required timeframes

Review provider policies and procedures for compliance with CMS mandated HCBS standards

Review and manage HCBS portal to ensure portal entries are reviewed and accepted prior to service initiation and move in

Collaborate with other MCOs when a member is transferred into the Alliance catchment area or transferred out of the Alliance catchment area

Work with providers to ensure out of compliance findings are remedied either by providing technical assistance and/or through a plan of correction

Work with I/DD Care Coordination, Provider Network Development and agency providers to ensure sites are validated and in compliance

Remediate issues and concerns that are identified by the State with MIE surveys through documentation review, technical assistance with providers and other stakeholders, and collaboration with I/DD Care Coordinators

Provide reports and updates on outcomes of reviews of HCBS and the potential impact on consumers involved to the Provider Network Evaluator Supervisor and/or the Director of Network Evaluation

Review and Monitor Individual and Family Directed Services

• Review self-directed services (Employer of Record) on an annual basis as required 
• Provide technical assistance when required to ensure compliance with CCP8-P, Attachment H and other mandated requirements
• Maintain EOR spreadsheet

Assist With Department Policies, Procedures, and Standards

• Assist in the development and maintenance of standards for HCBS and unlicensed AFLs sites, Individual and Family Directed Services (IFDS), quality improvement and evaluating the delivery of services to consumers and families
• Assist in the development of monitoring policies and procedures and site validation
• Assist in the development of MIE survey processes and procedures

Provide Monitoring Information for Inclusion in Provider Database

• Maintain a current database of HCBS sites that require monitoring and review
• Maintain a database of unlicensed AFL sites that require annual reviews. Work with I/DD care coordination as needed to update the database to capture sites that are new and sites that are no longer serving members
• Help maintain the database to ensure accuracy
• Track any discrepancies and errors in State required reports and reconcile as needed to ensure sites are validated and there are no disruptions in services
• Track I/DD Care Coordination HCBS assessments/reviews and communicate any discrepancies as needed

Maintain Knowledge of Current Services and Supports Available

• Acquire and maintain knowledge of the current services and supports available within the catchment area and available to consumers within North Carolina

Participate in Investigations and Focused Reviews

• In limited instances, the PNE I may be asked to participate in investigations and focused reviews when there are concerns about quality of care and health and safety

Travel

• Travel between Alliance offices, attending meetings on behalf of Alliance, participating in Alliance sponsored events, etc. may be required
• Travel to review sites, meet with members, providers, stakeholders, and attend court hearings etc. is required

Minimum Requirements

Education & Experience

A bachelor’s degree in a Human Service field (such as Psychology, Social Work, etc.) and at least five (5) years of progressive experience in the field of I/DD or TBI. 

Strong knowledge of I/DD and TBI services required. Experience with Home Based and Community Services (HCBS) is highly desired. 

Must maintain a valid driver’s license and a good driving record.

Knowledge, Skills, & Abilities

• Working knowledge of federal and state statutes, rules, definitions and regulations that govern MHDDSAS services
• Knowledge of all disability areas including Mental Health, Developmental Disabilities and Substance Abuse
• Extensive knowledge of I/DD and TBI services and requirements
• 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
• Microsoft Office skills
• Ability to identify/analyze administrative problems pertinent to the contract 
• Ability to make independent judgments, logical conclusions, recommendations and decisions
• Ability to determine the appropriate course of action in an emergency or stressful situation
• Ability to maintain confidentiality both of consumer data and provider business practices
• Ability to review and analyze data in an effort to evaluate program effectiveness, progress, problems and system performance
• Ability to work effectively with others internally and externally

Salary Range

$25.75 - $32.83/Hourly

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 Term Disability
• Generous retirement savings plan
• Flexible work schedules including hybrid/remote options
• Paid time off including vacation, sick leave, holiday, management leave
• Dress flexibility