19 days old

Provider Network Evaluator II

Alliance Health
Morrisville, NC 27560
  • Job Code

The Provider Network Evaluator II will be part of the Targeted Monitoring Review team. The PNE II will be responsible for ensuring provider adherence to MCO rules and guidelines in order to ensure sufficient, safe, and effective services are being provided to consumers who have been identified as having Mental Health, Developmental Disabilities or Substance Abuse needs. The Provider Network Evaluator II will uphold the integrity of the organization by monitoring in a fair, impartial manner, while providing technical assistance as appropriate to assist providers in delivery of quality services. The Provider Network Evaluator II will perform non-routine monitoring, performance profile reviews and investigate instances of concerns so that this objective can be met by the providers.The Provider Network Evaluator II will employ clinical knowledge and skills to ensure that services are provided in a manner that meets clinical coverage requirements and best practice. The Provider Network Evaluator II will perform these duties for the benefit of the MCO and the health and wellness of the consumers being served under the MCO.

Duties and Responsibilities

  • Conducts investigations and focused monitorings to address grievances, health and safety and quality of care concerns. Acts as lead clinical investigator where appropriate;

  • Ensures that all mental health/I-DD/SA programs, services, and systems are provided in accordance with Local, State and Federal Performance Standards, and congruent with organizational and procedures manuals;

  • Acquires and maintains knowledge of the current services and supports available within the catchment area and available to consumers within North Carolina;

  • Using clinical expertise, effectively interprets qualitative and quantitative provider information to appropriately document findings.

  • Reviews State Plan documents, MCO Business Plan, Provider Operations Manual and Clinical Service Guidelines to ensure local services/system development are in compliance;

  • Provides assistance and consultation to assure that written policies and procedures are kept current with the aforementioned;

  • Be knowledgeable of the clinical requirements of the service definitions within provider contracts as well as other contractual requirements. Provides input into the development/termination of contracts;

  • Reports to Provider Network Evaluator Supervisor on outcomes of investigations and focused monitorings and the potential impact on consumers involved;

  • Works with Provider Network Team to maintain a provider database which will include information gathered from monitoring activities;

  • Collaborates with the Quality Management Unit and Service Management Units in the development of meaningful quality indicators, Provider profile elements and Provider database;

  • Assists in the development of MCO standards for service monitoring, quality improvement and evaluating the delivery of services to consumers and families;

  • Develops and/or assists in the non-routine monitoring policies and procedures pertaining to behavioral health, substance abuse, and I-DD services;

  • Participates in professional development activities and organized community events;

  • Participates in training and other staff development activities;

  • Performs other duties as assigned.


Requires a Masters degree in a Human Services field (such as Psychology, Social Work, etc.) and a minimum of three years post Masters degree of progressive experience in the field of mental health, developmental disabilities or substance abuse. Must maintain a valid drivers license and a good driving record.Current and active licensure by North Carolina Licensure Board as a LCSW, LPC (this credential is now LCMHC), LPA, LCAS or LMFT is required.

Knowledge and Skills

  • Exceptional interpersonal skills and highly effective communication ability.

  • Ability to work effectively with both internal and externally partners and community stakeholders in order to foster collaboration and positive relationships.

  • Ability to work independently with limited supervision; must be able to successfully perform task and make critical business decisions, leading to successful outcomes.

  • Problem solving and conflict resolution skills are essential.

  • Must have a working knowledge of federal and state statutes, rules, definitions and regulations that govern MHDDSAS services.

  • Having the ability to review and analyze data in an effort to evaluate program effectiveness, progress, problems and system performance is essential.

  • Ability to identify/analyze administrative problems pertinent to the contract, make independent judgments, logical conclusions, recommendations and decisions.

  • Knowledge of all disability areas including Mental Health, Developmental Disabilities and Substance Abuse is vital. This knowledge base must include an understanding of principles, concepts and Best Practices used in the treatment, habilitation and support of individuals with needs in any of the disability areas.

Additional Training Preferred

Experience in any of the following areas would be valuable for this employee: Public speaking, mediation, presentation development, group facilitation, advocacy, regulations compliance and project management.

Candidates with having experience working with or in LME/MCOs, monitoring experience, familiarity with clinical reviews and/or QM experience would be an advantage to the role.

Salary Range

$53,434 - $91,985

Licenses & Certifications


  • Driver License



  • Diplomacy

  • Verbal Communication

  • Written Communication

  • Collaboration

  • Task Management



  • Enthusiastic: Shows intense and eager enjoyment and interest

  • Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well

  • Team Player: Works well as a member of a group



  • Self-Starter: Inspired to perform without outside help

  • Ability to Make an Impact: Inspired to perform well by the ability to contribute to the success of a project or the organization

See job description

Posted: 2021-01-05 Expires: 2021-02-03
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Provider Network Evaluator II

Alliance Health
Morrisville, NC 27560

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