The External Clinical Quality Analyst II manages the quality review process for
provider-led care management programs. Incumbents conduct quality reviews and
audits of provider-led care management programs and processes for quality
assurance purposes and to support the effective functioning of provider-led care
management.
This position is full-time remote. Selected candidate must reside in North
Carolina. Some travel for onsite meetings to the Home office may be required.
Responsibilities & Duties
Analyze Care Management documentation and activities to ensure compliance
Review the quality of provider-led Care Management programs by completing
administrative reviews is coupled with detailed clinical case reviews for
alignment with all requirements identified in the NC DHHS Tailored Care
Management Provider Manual.
Audit provider-led Care Management policy and procedures, staffing, training,
and provision of all Care Management activities including clinical
documentation to ensure alignment with program descriptions, workflows,
evidence based clinical guidelines, NCQA guidelines, CMS guidelines, and
regulatory guidelines (when applicable).
Analyze program data to identify trends and to develop and implement
corrective action plans as appropriate.
Interpret qualitative and quantitative information to appropriately document
findings and ensure contractual requirements are met.
Identify system and/or operational issues hindering the attainment of quality
performance standards as defined by NCQA standards, applicable state and
Federal laws and regulations
Analyze Data and Report on findings
Provide written feedback to the Senior Director of Network Evaluations,
Practice Transformation Team, and Compliance concerning quality concerns
pertaining to program performance, and compliance risks/trends
Evaluate knowledge gaps of staff and coordinate training
Evaluate knowledge gaps of the provider-led Care Management staff and
collaborate with Provider Network, Practice Transformation and Care
Management Leadership to coordinate learning and training opportunities for
provider-led Care Management entities
Minimum Requirements
Education & Experience
Master’s degree in Health, Psychology, Sociology, Social Work, or another
relevant Human Services field from an accredited college/university with a North
Carolina Clinical license (LCSW, LCMHC, LMFT, LPA) and three (3) years of
experience providing care management to individuals in the following
populations; Traumatic Brain Injuries (TBI), Intellectual/Developmental
Disabilities (I/DD), Mental Health/Substance Use Disorders (MH/SUD), Severe
Mental Illness (SMI), or Physical Health (PH)
Or
Graduation from an accredited school of nursing with a Registered Nurse (RN)
license and three (3) years of experience providing care management to
individuals in the following populations; Traumatic Brain Injuries (TBI),
Intellectual/Developmental Disabilities (I/DD), Mental Health/Substance Use
Disorders (MH/SUD), Severe Mental Illness (SMI), or Physical Health (PH)
(3) years of experience providing care management to individuals in the
following populations; Mental Health/Substance Use Disorders (MH/SUD), Severe
Mental Illness (SMI), Intellectual/Developmental Disabilities (I/DD), Traumatic
Brain Injuries (TBI), or Physical Health (PH)
Required experience
Experience with Care plans, comprehensive assessments, care management
interventions, and service engagement activities, or
Medicaid Managed Care, or
Integrated care (behavioral and physical health), or
Program/services monitoring, program evaluation
Special Requirement
Current, active, unrestricted NC clinical license such as RN, LCSW, LMHC, or
LMFT to practice as a health professional within the scope of licensure in the
state of North Carolina.
Preferred Experience
Auditing Clinical documentation
Preferred Certification
Certified Care Manager (CCM)
Knowledge, Skills, & Abilities
Knowledge of North Carolina State and Federal rules and requirements related
to the service continuum in North Carolina
Knowledge of Tailored Plan, Integrated Care and Care Management processes and
regulatory requirements
Knowledge of best and promising practices for behavioral & physical health
and/or intellectual/developmental disabilities
Microsoft Excel, Word, PowerPoint, SPSS, and Survey Monkey (or other online
survey tool)
Strong clinical skills
Strong verbal and written communication skills. Ability to write clear,
accurate and concise rationale in support of findings.
Ability to interpret contractual agreements, business-oriented statistics,
medical/administrative services and records.
Analytical skills and ability to make deductions; logical and sequential
thinker.
Problem solving and conflict resolution skills
High degree of integrity and confidentiality required handling information
that is considered personal and confidential.
Highly effective communication skills
Ability to manage time, prioritize work, and use problem-solving approaches
Salary Range
$69,592 - $88,729/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, 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