Alliance Health

The Clinical Planning and Policy Analyst is responsible for supporting the policy analysis, writing and research activities by identifying, obtaining, organizing and analyzing quantitative and qualitative data, reviewing academic and professional literature and gathering information from multiple sources on cost, utilization, quality and access to health care services.  This role is pivotal in shaping healthcare policies that address critical challenges and promote equitable and efficient healthcare delivery. The position requires strong analytical, communication and management skills. Additionally this position supports documents management activities within the Clinical Planning and Policy team. This position is full-time remote. Selected candidate must reside in North Carolina and be willing to travel to the home office (Morrisville, NC)  for   onsite team meetings as needed. Responsibilities & Duties Medical Policy and Clinical Practice Guidelines...

The Risk Manager is responsible for leading and continuously maturing the organization’s Enterprise Risk Management (ERM) program for a Medicaid managed care organization. Reporting to the Chief Risk and Compliance Officer, this role provides second line oversight and enterprise wide coordination to ensure that material risks—strategic, operational, regulatory, financial, reputational, and third party—are identified, assessed, communicated, and managed in alignment with organizational objectives and risk appetite. The Risk Manager serves as the enterprise steward of the ERM framework, risk register, and risk reporting, partnering closely with business leaders, Compliance, Internal Audit, Program Integrity, and Privacy and Health Information Governance. The role also provides governance and oversight for organizational insurance and risk financing activities, incident and event trending, business continuity and preparedness, and selected operational risk domains (e.g.,...

The Care Manager l-Non-Waiver assures that individuals and families with special health care needs receive integrated whole-person care management, including coordinating across physical health, behavioral health, pharmacy and unmet health-related resource needs to ensure they are linked to services and supports in an effort to maximize potential outcomes and decrease the unnecessary use of hospitals and emergency services by assuring that appropriate quality care is in place.  The Care Manager I – Non-Wavier focuses on a specified population of members utilizing health care services while ensuring all member health needs and referrals are attended to. The Care Manager l will collaborate with other community systems to work in partnership to support the identified population. 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...

The Care Manager II position leads all communication among care team members and is the primary point of contact for the member served.  The Care Manager completes a comprehensive assessment and develops a unified plan of care for Tailored Plan recipients and relays communication among providers of health services. This is a full-time hybrid opportunity. There is no expectation of coming into the office routinely, however, the selected candidate must be available to report onsite to the Alliance Office (Morrisville) for business meetings as needed. The successful candidate will also be required to travel weekly throughout Harnett County to meet with members, providers and/or other community stakeholders. Responsibilities & Duties Complete Assessment/Planning Complete comprehensive assessments at enrollment, yearly or at changes in condition. Develop Plans of Care derived from the completed assessments Assign interventions/plans of care...

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 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...