Provider Network Evaluator II-Targeted (Full-time Remote, North Carolina based)

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 irregulariti