Alliance Health

• Serve as the project management lead and subject matter expert for NCQA standards • Manage the assessment of related business functions for corresponding departments • Implement and monitor accreditation workplan • Identify gaps and risks and provide regular status reports • Serve as lead for NCQA Accreditation reviews by gathering necessary documents • Review and update policies and procedures, reports, and materials for compliance • Provide technical support and education to staff regarding NCQA Health Plan Accreditation • Assess business area functions against NCQA standards • Identify and facilitate process improvements • Communicate reporting due dates and reminders to business leads • Lead compliance review for non-clinical standards

Role Description 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 against developed clinical guidelines within contractually mandated turn-around times. - Conducts utilization reviews to monitor adherence to clinical practice guidelines and best practice standards and to determine if services were delivered as requested. - Engages in care management activities to ensure individuals receive appropriate referral for treatment including consumer and provider follow-up calls, case staffing with psychologists and medical staff. - Monitors consumer person-centered plans to ensure that effective treatment interventions are utilized, providing consultation to treating providers when person-centered plans require adjustments to better meet consumer needs. - Monitors and reports consumer and provider specific over/under utilization. - Conducts utilization reviews to monitor for over/under utilization. - Program Operation and Management - Identifies high-risk consumers and those with special health care needs for referral to Care Coordination and case escalation. - Provides linkage, authorizations, and level of care determinations, assisting providers and Care Coordinators with creative problem solving to recommend alternative approaches to care. - Ensures compliance with care management and quality improvement policies and procedures, utilization review laws and regulations, state standards. - Promotes access to appropriate, effective, and quality treatment. - Monitors for undesirable performance or deviations of practice standards through care management activities that may have a negative impact on consumers. Responds through additional follow-up with consumers and providers, provider technical assistance, and/or referral to other departments within the MCO. - Administrative Functions - Notifies members of adverse benefit determinations while preserving members’ Due Process rights. - Engages in routine follow-up to ensure consumers are engaged in treatment and services are being delivered as requested. - Documents utilization review decisions in computerized authorization management system. - Maintains professional licensure. - Engages in training as needed to stay informed of changes in best practice for supporting the needs of individuals with MH/SUD/IDD. Qualifications - Required: - Master’s degree in a Human Services field (such as Psychology, Social Work, or Counseling) and at least five years of post-degree progressive experience providing similar services to the population served (MH/SUD). - Current and active license issued by a North Carolina Professional Board, as a LCSW, LCAS, LP, LPA, LMFT, LCMHC, or RN. - A master's degree in psychiatric nursing which provides the knowledge, skills, and abilities needed to perform this work; or graduation from a State accredited school of nursing and two years of experience in psychiatric nursing which provides the knowledge, skills, and abilities needed to perform the work; or an equivalent combination of education and experience. - Preferred: - Experience in the public behavioral healthcare field is highly desired due to the complexity of the work. - Experience in a UM environment in Behavioral Healthcare would be valuable for this employee. Knowledge, Skills, & Abilities - Considerable knowledge of case management principles, practices, and applications. - Considerable knowledge of agency and community programs and services which affect clients and applicants. - Knowledge of state and federal client rights protection statutes and regulations applicable laws and regulations including but not limited to URAC, applicable Code of Federal Regulations, and NC Administrative Code. - Effective written and oral communication skills and interpersonal and presentation skills. - Ability to identify rights protection complaint issues; ability to set, monitor, and evaluate standards for quality and to assess plans to measure how they meet the needs of individual clients. - Considerable knowledge in DSM 5 diagnostic criteria. - Ability to manage time, prioritize work, and use problem-solving approaches. - Ability to coordinate effectively with staff from various agencies as well as inter-departmental. - Ability to read, analyze, and interpret regulations, policies, and procedures. - Ability to operate computer equipment and generate reports and records; ability to express ideas clearly and concisely orally and in written documents. - Proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.) is required. Salary Range $68,227 - $86,990/Annually. Exact compensation will be determined based on the candidate's education, experience, external market data, and consideration of internal equity. Benefits - Medical, Dental, Vision, Life, Long Term Disability. - Generous retirement savings plan. - Flexible work schedules including hybrid/remote options. - Paid time off including vacation, sick leave, holiday, management leave. - Dress flexibility.

• Perform a full range of legal services in support of Alliance • Mitigate legal risk through practice in a variety of legal areas • Provide legal support in contracts including drafting and advising • Perform legal research and analysis, gather and analyze information • Represent Alliance in all stages of legal challenges • Communicate with external stakeholders and support consumer relations • Stay accessible to Alliance as needed

The Transition Coordinator II Supervisor provides oversight to Transition Coordinator, a team of licensed and non-licensed staff who provide or assist with the provision of Transitional Care Management for members with physical and/or behavioral health needs in Acute Care facilities, State Operated Developmental Centers, and Justice System settings. Our Transition Coordinator Supervisor may also provide oversight for Transition Coordinator staff dedicated to processing and conducting Warm Hand Offs to Provider Led Entities and other Plans. 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 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 goals and to support employees and ensure compliance with licensure, regulatory, and accreditation requirements - Actively establish and promote a positive, diverse, and inclusive working environment that builds trust - Ensure all staff are treated with respect and dignity - Ensure standards are transparent and applied consistently, impartially, and ethically over time and across all staff members - Work to resolve conflicts and disputes, ensuring that all participants are given a voice - Set goals for performance and deadlines in line with organization goals and vision - Effectively communicate feedback and provide ongoing coaching and mentoring to staff and support a learning environment to advance team skills and professional development - Cultivate and encourage efforts to expand cross-team collaboration and partnership Supervise Unit Operations - Participate in the initiation, development, and maintenance of clinical protocols and other population-based programs, facilitating collaboration and consensus of multidisciplinary teams as complete care is developed - Oversee the development of department specific goals and objectives ensuring alignment with system strategy, vision, mission, and values - Formulate, implement, and evaluate strategies for specialized staff education as it relates to member care, case management and plans of care Provide Customer Service - Develop strong working relationships with providers and internal/external stakeholders by scheduling ongoing opportunities to share feedback and collaborate - Exercise conflict resolution skills to appropriately resolve issues with providers and internal/external stakeholders - Develop strong working relationships among the department and provide customer services with providers and stakeholders internal/external by scheduling ongoing opportunities to share feedback and collaborate Quality/Data/Analytics - Review, validate and interpret risk stratification data and population health groups and recommends changes or adjustments to care management approach as needed - Utilize data systems to monitor process improvement and resource utilization - Knowledgeable of HEDIS measurements and population health within a complete care model - Utilize evidence-based practice to ensure quality outcomes for members Compliance with Alliance Policy and Procedure - Ensure adherence to all Alliance Organizational Policies and Procedures and Care Management Desk Procedures Continuous Quality Improvement - Make recommendations to improve department procedures and increase operational efficiency - Monitor trends and identify opportunities for enhancements in service utilization and implementation throughout the organization Minimum Requirements Education & Experience Graduation from an accredited school of nursing with Registered Nurse license and five (5) years of experience with at least two (2) years of applicable experience with the population served, including experience with case management/discharge planning in one of the following settings: Acute care, Home care, LTC care, Physician Office or Managed Care Or Master’s degree in Human Services from an accredited college or university and three (3) years post graduate degree experience with at least two years of applicable experience with the population served, including experience with case management/discharge planning in one of the following settings: Acute care, Home care, LTC care, Physician Office or Managed Care. Must have a valid, active clinical license as a LCSW, LMFT, LCAS, LCMHC, LPA, or RN in North Carolina. Preferred: Two (2) years supervisory experience and CM or CCM certification preferred. Knowledge, Skills, & Abilities - Knowledge and understanding of the Diagnostic and Statistical Manual of Mental Disorders (current version) and ICD-10 coding - Considerable knowledge of the MH/SUD/IDD service array provided through the network of the Applicant’s providers. - Knowledge in the implementation of the 1915 (b/c) waivers and national accreditation is essential. - Knowledge of and skilled in the use of MS Office Products including Outlook, Excel and Word - Detail-oriented and able to organize extensive amounts of clinical data, multiple tasks and priorities - Knowledge of research and best practice development in clinical practice, - Knowledge of Utilization Management/Utilization review and other related areas - Knowledge of Tailored Plan standards or procedures - Knowledge of the NC Division of Mental Health, Developmental Disabilities and - Substance Abuse IPRS Target Populations and Service Array - Knowledge of 1915(b) and NC Innovations Waiver - Knowledge of Medicaid and Innovations Service Array - Knowledge of applicable Federal laws, including Substance Abuse and HIPAA Privacy Laws. - Knowledge of National Accreditation standards and regulations - Ability to effectively manage projects from start to finish - Ability to adapt and shift focus according to mandated changes and changing priorities within the department. - Ability to access and interpret information and propose solutions to address issues and specific consumer needs and situations. - High level of diplomacy and discretion - Ability to effectively negotiate and resolve issues with minimal assistance. - Exceptional interpersonal skills - Ability to communicate effective orally and written - Ability to make prompt, independent decision based on relevant facts - Problem solving, negotiation, and conflict resolutions skills - Highly skilled at assuring that both long- and short-range goals and needs of the individual are addressed and updated, while also assuring through monitoring activities that service implementation is occurring appropriately. Employment for this position is contingent upon a satisfactory background and MVR (Motor Vehicle Registration) check, which will be performed after acceptance of an offer of employment and prior to the employee's start date. Salary Range $77,868 - $99,282 Annually Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity An excellent fringe benefit package accompanies the salary, which includes: - Medical, Dental, Vision, Life, Long Term Disability - Generous retirement savings plan - Flexible work schedules including hybrid/remote options - Paid time off including vacation, sick leave, holiday, management leave - Dress flexibility Want to learn more about what it's like work as part of the Care Management Team? Click on our video to learn more: https://youtu.be/1GZOBFx61QU

• Serve as the project management lead and subject matter expert for assigned NCQA standard areas • Manage the assessment of related business functions for corresponding departments within the scope of NCQA standards • Support high-quality performance and ensure successful NCQA Accreditation process • Support the Continuous Quality Improvement Committee • Implement and Monitor Accreditation Workplan • Identify gaps and risks and provide regular status reports from NCQA tracker to leadership • Serve as lead for NCQA Accreditation reviews for assigned standard categories • Review and update policies and procedures, reports, materials, and files for completeness, accuracy, and compliance with NCQA Standards • Maintain calendar of documentation due dates • Participate in Delegation Oversight and audits as appropriate • Provide technical support and education to staff regarding NCQA Health Plan Accreditation • Assess business area functions against current and upcoming NCQA standards • Coordinate and collaborate with cross-departmental teams to identify and implement organization-wide strategic initiatives that support quality performance

• Drive internal audit initiatives, special projects, and improvement initiatives in accordance with the Institute of Internal Auditors (IIA) Global Internal Audit Standards, including requirements for planning, performing, and communicating results • Develop and apply audit criteria and performance measures for assigned engagements • Apply IIA-aligned audit methodology when evaluating the adequacy, effectiveness, and efficiency of internal controls and ongoing operations • Provide task assignments, guidance, and initial workpaper review for Internal Auditor I staff • Perform detailed reviews of workpapers to ensure IIA expectations for evidence quality, analysis, and documentation are met • Conduct periodic audit follow-ups to assess and report on progress or completion of management’s corrective actions • Conduct other audit and compliance activities, such as internal investigations, as assigned • Prepare audit and advisory reports for Director of Internal Audit review • Apply the IIA’s guidance on risk assessment and prioritization when developing engagement-level audit objectives and testing strategies • Design audit programs and testing procedures consistent with IIA guidance on planning and due professional care • Maintain and refine internal audit methodology, including policies, procedures, templates, and tools • Align audit activities with internal audit strategy, goals, and objectives • Assist in defining and managing content for the internal audit manual • Contribute to the development of the internal audit training program; work with supervisor to establish training goals • Participate in organizational risk management activities, including contributing to the annual risk assessment that informs the audit plan • Assist in the annual system-wide Enterprise Risk Management risk assessment cycle • Support protocols to promote consistent use of IIA audit methodology • Provide input on staff development needs and support skill‑building activities • Support consistent application of IIA Standards by answering questions and helping staff resolve methodological issues • Assist with occasional knowledge sharing or focused training, as needed, to strengthen team capability • Provide mentoring and coaching to internal auditor staff and compliance auditors (analysts) • Effectively communicate with internal audit staff, Director of Internal audit, and Alliance management • Build relationships with key constituents and serve as a resource of professional audit advice, as appropriate • Build and nurture key management and business relationships • Manage external relationships, i.e. with external auditors, regulators and consultants • Document audit results accurately and completely using the designated internal audit software • Communicate the results of audit activities via written reports and oral presentations to appropriate management and other stakeholders

• Provide a range of care management and support functions to help ensure members on the Innovations and TBI waiver receive needed Home Modifications, vehicle modifications, Assistive Technology and Equipment (ATES) and service benefits available under these waivers. • Provide education about Alliance Health Plan, relevant waiver and available support, resources, and services to orient new members, and their legally responsible person, receiving slots about benefits of the Innovation and TBI waiver. • Complete Assessment/Planning and demonstrate commitment to whole person/integrated care. • Complete required Screening Tools for members new to the waiver. • Collect necessary assessments related to member need for home modifications, vehicle modification and other assistive technology. • Ensure the timely delivery of services - and trouble shoot until authorization is obtained. • Coordinate with other team members to ensure smooth transition to appropriate level of care when needed. • Communicate with member to check on status, verify care needs are met and that no new clinical needs warrant a change in condition assessment. • Make service referrals for new waiver members, Residential placements, Home Modifications, and Assisted Technology and Supplies. • Document all applicable member updates and activities per organizational procedure. • Mentor new Care Managers and provide shadow opportunities for Risk assessment and Plan of Care development.

• The primary purpose of the UI Application Developer is to create and maintain Alliance Claims processing front end solution. • This includes designing and implementing a well-formed, component-based, testable, well-integrated library of components. • The position will also be responsible for and demonstrate the ability to be creative in designing and implementing appropriate UI/UX designs. • Build and implement secure, efficient, and visually aesthetic user interfaces using JavaScript/TypeScript and the Angular framework with HTML and CSS/SCSS. • Create an adaptable and secure interface applying the latest front-end technology and security best practices. • Lead product-analysis tasks and conduct performance tests. • Implement complex components that will include significant research and analysis. • Ensure a clear dependency chain, regarding the app logic as well as the file system. • Collaborate with other developers and QE team members to ensure security, high-performance and reliability of the applications. • Interact with business teams to understand project and new feature requirements. • Interact with support staff to identify and resolve escalated production level helpdesk bugs, bottlenecks, and obstacles. • Participate in meetings to provide valid input in application architectural discussions and status updates of current development. • Document and manage development tasks using TFS.

• The Contract Administrator manages all administrative and procedural components of provider contracts (Medicaid and Non-Medicaid) throughout the contract lifecycle, including but not limited to ensuring compliance with company contract templates, standards, and other key process controls • This includes implementation, completion and ongoing follow-up of various managed-care contracts, amendments, and other related document for entities within Alliance Health’s integrated delivery system • Assist in development and maintaining effective relationships with payors and internal stakeholders • Communicate contract terms and/or facilitate follow up with General Counsel to providers and work with other internal departments to implement improvements in the contracting process • Manage the full life cycle of provider contracts, including timely preparation of contract documents while giving special attention to language and accuracy, dissemination of contracts to providers within MCO-identified timeframes, follow-up of agreement status to ensure full execution, as well as accurate processing of executed contracts including completing all required organization forms, checklists, and data entry • Review any modifications, confirm executed contractual terms and conditions meet MCO requirements, and confirm all attachments are complete • Ensure contract elements are loaded correctly, timely and meet legal and business standards • Interface with IT Department to ensure data integrity and accuracy of contract details and ensure all required data elements are entered into the Alliance Claims System • Create the provider profile in accordance with all services the provider is contracted to provide, and ensure all appropriate rates are included; data must be accurate and timely to support claims processing • Provide guidance and technical assistance to Alliance providers regarding the processing of contracts as well as ongoing resolution of any contract-related issues • Help to address provider questions and complaints related to contracting issues and engage Provider Network Relations Staff as needed • Investigate consumer/provider service discrepancies in contract details as requested and report findings • Organize, maintain and electronically track all contract and related documents • Ensure the contract database system functions properly to serve Alliance needs and prepare and distribute reports to facilitate planning and maintenance of accurate contract records and files • Manage contract files per department procedures and participate in development of time-phased plans for renewal of contracts to support anticipated requirements • Work collaboratively with cross-departmental staff members to ensure contract deadlines are met and resolve contract-related issues • Establish and maintain strong business relationships with Hospitals, Physician Groups, LIPs and Ancillary providers.