Alliance Health

The Member and Recipient Services Coordinator provide a broad range of customer service functions to individuals that contact the Tailored Plan (TP) Member and Recipient Services Call Center. This position provides general information regarding accessing services in the TP provider network, and on the various functions and processes of TP departments.  This position assures consumers/guardians seeking routine services are referred to services or are transferred to licensed clinicians for clinical screening and triage. 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 and Duties Customer Service & Support Receive calls from members, recipients, and community stakeholders Provide education to callers regarding all areas of TP functions Availability and appropriateness of contracted providers; General information about managed care and NC...

The Claims Research Analyst reviews and monitors adjudicated claims for file submission and upstream processing and communicates with provider agencies on claims submission, denial management, and system updates. This position serves to provide excellent customer service to provider agencies. This position facilitates training of providers and provides intermediate technical assistance. This position reviews auto-adjudicated claims and manually processes claims that pend for manual pricing or high impact criteria. This position analyzes available billing requirements, policies, procedures, and desk references to ensure proper protocol is practiced to accurately process claims. The CRA demonstrates and utilizes advanced analytical skills to process complex claims, analyze data, identify system issues, and utilize/build reports to enhance overall unit performance. This position aids in the leadership of the unit through facilitation of meetings, trainings, and process improvement...

The NCQA Quality & Accreditation Analyst serves as the project management lead and subject matter expert for assigned NCQA standard areas and manages the assessment of related business functions for corresponding departments within the scope of NCQA standards (e.g. Provider and Member Services, Utilization Management, Population Health, Care Management, Provider Network, Member and Provider Communications, Delegation Oversight) to support high-quality performance and ensure successful NCQA Accreditation process. Additionally, this role supports the Continuous Quality Improvement Committee. This position is fulltime remote. Selected candidate must reside in North Carolina. Some travel for onsite meetings at the Home office (Morrisville, NC) may be required. Responsibilities & Duties Implement and Monitor Accreditation Workplan Project lead for assigned NCQA standard categories to achieve and maintain Health Plan Accreditation with LTSS distinction and...

The UM Clinical Specialist-Behavioral Health performs professional and administrative work, primarily utilization reviews, utilization management and active care management to ensure economical and effective consumer service delivery by PHIP enrolled network providers; The position is responsible for providing medical necessity reviews of individualized service plans and requests for authorization of services to ensure consumers receive services in the least restrictive, most integrated setting appropriate to the individual’s needs; The primary role is to review for services under the Medicaid B waiver and state funded benefits; complete related work as required. This position is full-time remote. The selected candidate must reside in North Carolina. Some travel for onsite meetings may be required. Responsibilities & Duties Utilization Reviews and Management Independently conducts medical necessity reviews of service requests submitted by service providers...

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-HCBS 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 position but does require travel to conduct on-site reviews and...

The Administrative Assistant III provides administrative support to the claims team to ensure the efficient operation of the team, including handling high volume incoming and outgoing mail and high-volume inbound calls. The Administrative Assistant III also completes specific claims-related responsibilities including performing a range of clerical tasks, maintaining databases and spreadsheets, conducting research, preparing reports, handling inquiries, receiving/screening/keying paper claims, and other activities that require knowledge of program operations, policies, and processes. Responsibilities & Duties Provide Administrative Support to Manager and Team Maintain files, reports and other data, including aggregating data from multiple sources and uploading documents to various systems within Alliance Manage organizational and departmental records and report on activities involving implementation of program objectives using existing procedures or...

The Justice Specialist is responsible for 1) identifying and connecting with justice partners amongst Alliance's region and building strong relationships; 2) facilitating community-based solutions to improve outcomes and engagement for persons who are involved with the justice system. This includes all diversion opportunities along the Sequential Intercept model of pre-booking, incarceration and post-booking release.  The Justice Specialist is responsible for improving system engagement with key partners and stakeholders. This position will allow the successful candidate to work a schedule that will be primarily remote. While there is no expectation of being in the office routinely, they will be required to come into the Alliance Office for business and team meetings as needed. This position will serve the Harnett and Johnston County areas.  Responsibilities & Duties Training Coordination  Perform community outreach, recruitment, education, and...

The Organizational Development (OD) Specialist II-Change Management is responsible for developing, implementing and evaluating strategies and initiatives to improve organizational effectiveness, specific to the function of Change Management and supporting organizational values and strategic goals. The Organizational Development (OD) Specialist II-Change Management facilitates the people-side of change; developing resources and interventions to guide change awareness, manage resistance and monitor progress on change initiatives. This  rol e will report to the Organizational Development Manager.  This position is fulltime remote. Selected candidate must reside in 100 miles of Morrisville, North Carolina. Some travel for onsite meetings to the Home office at Morrisville may be required. Responsibilities & Duties   Change Management Develop and implement change management strategies and interventions that focus on the people side of...

The Assistant General Counsel is responsible for performing a full range of legal services in support of Alliance as a member of the Alliance Office of Legal and Public Affairs. The work of the Assistant General Counsel will serve to mitigate legal risk to the organization through practice in a variety of legal areas pertinent to Alliance’s mission and to do so with a measured approach to utilization of outside counsel.    This position is full-time remote. Selected candidate must reside in North Carolina and be willing to travel to court appearances in the Eastern part of the state as needed. Additionally, job duties may require selected candidate to be onsite at Alliance’s offices, judicial forums, and other community locations as needed. Responsibilities & Duties General Legal Support Provide legal support to Alliance in all contracts necessary to Alliance functions including drafting, negotiating and advising on contracts such as Medicaid and State...

The Vendor Relations Manager is responsible for overseeing the successful implementation, ongoing relationship and monitoring of large vendors serving Alliance members under delegated agreements and the contracts for Alliance’s value-added services program. This position serves as the intermediary between external vendors and internal subject matter experts and will be involved in the entire lifecycle of agency-wide contracts from negotiation through delivery.  This position is hybrid with ability to work three days remote. On Tuesday and Wednesday of every week the selected candidate must report onsite at Alliance's Home Office in Morrisville, NC. Responsibilities & Duties Manage and Develop staff Work with Human Resources to attract, maintain, and retain a highly qualified and well-trained workforce   Ensure staff are well trained in and comply with all organization and department policies, procedures, and business processes Organize...

The Physical Health Medical Director plays a key role within the Physical Health Medical Management Team, providing clinical oversight, medical expertise, and operational support for physical health services. This position ensures high quality, evidence based medical review processes and supports organizational goals related to clinical quality, utilization management, and care coordination. This position will allow the successful candidate to work primarily remote. While there is no expectation to be in the office routinely, the selected candidate may be required to report on-site as needed. It's strongly preferred that the selected candidate reside in North Carolina or be willing to relocate. This position may be required to work weekends and holidays based on organizational and operational requirements. Responsibilities & Duties Clinical Oversight & Medical Review Provide expert guidance and oversight for physical health service requests, including...

The Supervisor for Complex Case Management will provide supervision, coaching, and monitoring of the Complex Case Management team, a team of licensed clinicians responsible for coordinating care for members identified for Complex Case Management.  The position will ensure that the Complex Case Management team performs work that aligns with Alliance’s CCM program description and NCQA guidelines. This position is fulltime remote. Selected candidate must reside in North Carolina. Some travel for onsite meetings to the Home office may be required. Responsibilities & Duties Supervision and Development of Staff Work with Human Resources and Unit Director to maintain and retain a highly qualified and well-trained workforce  Ensure staff are well trained in and comply with all organization and department policies, procedures, business processes.  and workflows Ensure the department has the needed tools and resources to achieve organizational...

Care Management Liaison Supervisor is a licensed healthcare professional who provides oversight to Care Management Liaisons, a team of licensed and non-licensed staff who support Alliance members working with external entities (Primarily Primary Care Offices and Provider Led Entities) by providing consultation, training and assistance to ensure quality member care. The key responsibilities will include oversight, training, process development, and monitoring of staff activities. This supervisor communicates and collaborates with internal and external stakeholders to resolve barriers to services and resources. They are accountable for maintaining effective and efficient team workflow and reporting requirements to Alliance leadership and the State. 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 Supervise and Develop Staff Work with...

The Sr Psychologist – I/DD is a licensed professional who brings both clinical and health plan experience in intellectual and developmental disability (I/DD) to the Alliance Medical Management team, primarily performing utilization management (UM) activities (e.g., peer reviews, appeals) for requested services commonly used by Alliance members with I/DD, such as Research-Based Behavioral Health Treatment (RB-BHT) for Autism Spectrum Disorder (ASD) and services provided under the 1915(i) and Innovations Waivers, and secondarily as an internal subject matter expert (SME) on I/DD. This position is fulltime remote. Selected candidate must reside in North Carolina. Some travel for onsite meetings to the Home office at Morrisville may be required.  Responsibilities & Duties Clinical Oversight & Medical Review Provide Peer Review (second level review) to determine the medical necessity of authorization for services requested under NC Medicaid and relevant...