Provider Network Evaluator I-HCBS (Hybrid, North Carolina Based) at Alliance Health in Morrisville, North Carolina

Job Description:

The Provider Network Evaluator I ensures HCBS (Home and Community Based Services) sites are validated within the required timeframe and provider policies and procedures are in compliance with CMS standards for HCBS and conducts reviews for unlicensed Alternative Family Living (AFL) providers. The PNE I will also work to make sure that member responses to surveys are remediated when additional look behind reviews are triggered.

This position will allow the successful candidate to work a hybrid schedule, both remote and onsite. Candidates are required to travel to local communities primarily within Cumberland, Durham, Johnston, Wake and adjacent counties, as well as other sites within North Carolina as needed.

Responsibilities & Duties

Ensure that TBI, Innovation waiver, and B3-B3 DI 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 remedies 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 unlicensed AFLs to ensure compliance with state standards.

• Review and monitor unlicensed AFLs on an annual basis as required and perform initial reviews on new unlicensed AFLs.


• Provide technical assistance when necessary to ensure unlicensed AFLs are in compliance with mandated requirements 


• Issue and oversee plans of correction when required.

Investigate Safety and Quality of Care Concerns

• Conduct investigations and focused monitoring to address grievances, health and safety and quality of care concerns

Assist with department policies, procedures, and standards

• Assist in the development and maintenance of standards for HCBS and unlicensed AFLs sites, 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.


• 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

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

$41,767.55 to $71,901.76/Annually 

Education

Required

• Bachelors or better in Human Services

Skills

Required

• Communication


• Diplomacy


• Investigating


• Mediating


• Microsoft Office

See job description

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