The 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 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.
This position is full-time remote. Selected candidate must reside in North Carolina. Onsite travel is required to conduct reviews and monitoring.
Responsibilities & Duties
Ensure that TBI, Innovation waiver, 1915i, and LTCS (Long Term Care Supports) sites/services are valid to permit members to receive services from a new service location and/or maintain services at an existing site
Perform HCBS reviews and intensive on-site 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
Issue and oversee Plan of Correction implementation when required
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 data base of HCBS sites that require monitoring and review
Maintain a data base of unlicensed AFL sites that require annual reviews. Work with I/DD care coordination as needed to update the data base to capture sites that are new and sites that are no longer serving members
Help maintain the IFDS data bases 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 meet with members, providers, stakeholders, attend court hearings etc. is required
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
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
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 mental health, developmental disabilities or substance abuse.
Strong knowledge of I/DD and TBI services required. Experience with Home Based and Community Services (HCBS) is highly desired.
Special Requirements
Must maintain a valid driver’s license and a good driving record.
Salary Range
$25 - $31.88/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, Short and Long and Short Term Disability
• Generous retirement savings plan
• Flexible work schedules including hybrid/remote options
• Paid time off including vacation, sick leave, holiday, management leave
