External Clinical Quality Analyst II (Full-time Remote, North Carolina Based)

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)