Alliance Health
Morrisville, NC, USA
The PNE Targeted Reviewer II holds and maintains clinical licensure and is responsible for conducting focused and targeted reviews that may include health and safety reviews, quality of care issues, intensive incident report reviews, and determines the appropriateness of clinical services delivered by providers in the Alliance network. The PNE Targeted Reviewer II is required to review claims data, clinical documentation, provider contracts, policies, and procedures, conduct provider staff and stakeholder interviews, and review reference and regulatory materials, to identify out of compliance findings, overpayments, quality of care and health and safety issues, clinical concerns, and other irregularities. Due to the varying nature of Targeted Reviews, the PNE II Targeted Reviewer is responsible for the development of review tools specific to the scope of the review.
This position is full-time remote. Selected candidate must reside in North Carolina and within 60-mile...