Alliance Health

Analyst

• Review and monitor adjudicated claims for file submission and upstream processing
• Communicate with provider agencies and internal departments regarding claims submission, denial management, and system updates
• Track trends and patterns to identify irregularities in the ACS system
• Work with claims analyst to communicate claims issues
• Ensure contract service level agreements are met
• Research and resolve Encounter Denials
• Determine if claim processed appropriately in ACS
• Rebill encounter denial when appropriate
• Research State initiated encounter recoupments
• Ensure Service Level Agreement (SLA) Maintenance
• Assist in researching discrepancies
• Utilize the A/R system to manage encounter denials and recoupments
• Document current status of denials and recoupments
• Ensure appropriate coordination of benefits using billing and payment policies
• Maintain knowledge of current adjudication edits
• Provide information and feedback to the system team for process improvements
• Communicate with DMH/DHB to resolve complex encounter denials/issues

Encounter Analyst I

Accounting Manager

• Manage and Oversee the Daily Operations of the Month End Close Team in the Accounting Unit
• For all core responsibilities ensure proper backups are in place
• Ensure up-to-date processes and desk procedures are maintained so all procedures are documented
• Ensure all documentation (month end support, required reports, journal entries, etc.) related to the team's responsibilities are maintained and organized
• Ensure consistency and accuracy for all accounting processes including review and oversight of the month end close process, journal entries, cash management, vendor maintenance and provider recoupments
• Communicate changes and fluctuations in the financial statements to the Accounting Manager and Sr. Accounting Analyst
• Implement improvements that create more accuracy, streamline processes, allow for a quicker month end close and allow for better collaboration between departments
• Manage and Develop Staff
• Work with Human Resources and Accounting Manager 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, and business processes
• Organize workflows and ensure staff understand their roles and responsibilities
• 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
• Manage Submission of Required Reports and Ad-Hoc Reporting
• Ensure monthly reports to the Department of Health Benefits (DHB) and the Board of Directors are complete, accurate and submitted by the required deadline
• Review required updates to state reports and ensure they are implemented by the required deadline
• Complete ad-hoc reporting as needed
• Assist with the Management of Financial Audits
• Responsible for ensuring efficient and accurate audits for area of responsibility.
• Ensuring information provided to the auditors is clear and accurate
• Will be responsible for the quarterly SB-208 audit and will assist the Accounting Manager with the Annual Financial Statement Audit
• Responsible for Annual Sales & Use Tax Returns

Supervisor – Accounting

Research Analyst

• Review and monitor adjudicated claims for file submission and upstream processing
• Communicate with provider agencies on claims submission, denial management, and system updates
• Facilitate training of providers and provide intermediate technical assistance
• Analyze available billing requirements, policies, procedures, and desk references to ensure proper protocol is practiced to accurately process claims
• Demonstrate and utilize advanced analytical skills to process complex claims
• Monitor and resolve technical issues within the Claims system
• Communicate and conduct liaison work across multiple departments to resolve claims denials/issues
• Provide training, education, and technical assistance to provider agencies

Claims Research Analyst

Data Analyst

• Work collaboratively with Quality Management, IT, and other teams to gather and document HEDIS data requirements
• Perform integrated testing for data quality assurance
• Support HEDIS Data initiatives and develop reports to support decision making
• Perform activities to achieve improvement in HEDIS measures
• Ensure compliance with HEDIS technical specifications and guidelines
• Provide analysis of HEDIS measures and present results to management
• Manage clinical quality metrics and HEDIS processes
• Develop Reports and Data Visualization Solutions using SQL and BI concepts
• Ensure accuracy of developed reports and metrics for users
• Assist with HEDIS data assurance efforts and reporting activities
• Actively participate in Data Governance committee and documentation for HEDIS data and solutions

HEDIS Data Analyst

• Manage encounter/claims files
• Monitor and track outgoing 837 files to NC Tracks and EPS
• Monitor and track incoming 999 and 835 files from NC Tracks
• Monitor and track incoming XML files from EPS
• Track rebill files submitted by Encounter Team
• Monitor and track carve out files (separately from others) for TCM and Maternity services
• Conduct file transfers as needed, ensuring all files get to all appropriate locations through review and submission
• Monitor and track vendor files in the data warehouse
• Monitor and track vendor files in EPS
• Conduct data analysis and report findings
• Monitor and Report Denial Trends for NC Tracks/EPS (Alliance and Vendors)
• Monitor and Report File submission trends for both Alliance and Vendors
• Ensure accuracy, timeliness, and reconciliation of Service Level Agreement (SLA) files submitted
• Ensure accuracy of SLA files by monitoring the number of encounters sent upstream (by Alliance and vendors)
• Collect data on encounters that pass/fail (accept/error)- from vendor files compared to EPS representation
• Ensure timeliness of SLA file submission by monitoring and tracking files to ensure files are inclusive of all encounters and are sent within time limits
• Reconcile SLA files by monitoring and tracking paid amounts in the Encounter Processing System (EPS) for comparison against FRT values
• Monitor subdelegates’ (DME, Vision, NEMT, Pharmacy) file submissions and copies of files sent to the Alliance Claims Data Warehouse to ensure all are accounted for in a timely manner
• Manage encounter denials
• Assist team in encounter denial management when necessary (Medicaid and State Funding)

Encounter Analyst II

IT Support

• Provide coverage of the EVV Provider Helpdesk phone and e-mail queues
• Provide technical assistance to providers, addressing system and user issues
• Work collaboratively with Alliance’s Provider Network EVV Coordinator to monitor the EVV Provider Network email inbox
• Assist with onboarding new EVV providers
• Answer and track queries, addressing system and user issues in a timely and professional manner
• Serve as a liaison between Alliance Health and HHAeX Exchange Support Help Desk and HHAeX Client Success team
• Manage records and reports activities involving implementation of EVV program objectives
• Write, edit, or coordinate the preparation of correspondence, reports, or other printed material

Provider Network Helpdesk EVV Specialist

• Leads a high-performing team focused on delivering impactful, data-driven insights that shape strategic direction across Alliance Health.
• Guides the development of integrated, high-value data products that transform complex data into actionable intelligence.
• Provides both technical and analytical leadership, ensuring the team delivers innovative, scalable solutions that address key business challenges and support data-informed decision-making at all levels of the organization.
• Supervises and develops employees and projects.
• Works with Human Resources to attract, maintain, and retain a highly qualified and well-trained workforce.
• Leads, trains, and develops the members of the Business Intelligence Analysts team and assists them in delivering high-quality data products.
• Ensures staff are well trained in and comply with all organization and department policies, procedures, and business processes.
• Organizes workflows and ensures staff understand their roles and responsibilities.
• Actively establishes and promotes a positive, diverse, and inclusive working environment that builds trust.
• Communicates and collaborates with internal stakeholders effectively.
• Participates in business analysis activities to gather required reporting and business requirements and translates requirements into technical specifications.
• Designs and develops data products that meet data and business requirements using SQL, Python, R and/or other supported languages.
• Conducts quality assurance tests and reviews data products to ensure that requirements are met and that they are developed in line with development standards and best practices.

Supervisor – Business Intelligence (BI) Analyst

Consultant

• Provide physical health and functional assessments and transition planning assistance
• Support members transitioning from institutional care settings to community-based care
• Perform individual assessments/screenings for medically fragile members
• Provide education regarding self-care strategies and available treatment options
• Actively collaborate with care team members

Complex Care Consultant, OT

Manager

• Complete comprehensive assessments or Care Needs Screening at enrollment, yearly or at changes in condition.
• Develop Plans of Care derived from the completed assessments.
• Demonstrate commitment to whole person/integrated care.
• Submit referrals to the Transition Coordinator when a physical health or behavioral health need indicates medical and/or pharmaceutical complexity.
• Assist in collecting data to be used to identify and address barriers as well as determine the effectiveness of care management/care coordination in reducing lengths of stay and use of emergency services.
• Schedule initial contact with member for purpose of assessment and engagement.
• Provide education and support, to individuals and LRP, in learning about and exercising rights.
• Recognize and report critical incidents and provider quality concerns to supervisors and Quality Management Department.

Care Manager I – Non-Waiver

• Complete comprehensive assessments at enrollment, yearly or at changes in condition
• Develop Plans of Care derived from the completed assessments
• Submit referral to the Integrated Health Consultant when a physical health or behavioral health need indicates medical and/or pharmaceutical complexity
• Submit required documentation to UM to ensure timely delivery of services and troubleshoot until authorization is obtained
• Promote customer satisfaction through ongoing communication and timely follow-up on any concerns/issues

Care Manager II

• Gather and document reporting requirements and then design, develop, implement and support routine mission-critical reports
• Identify areas in need of enhanced reporting solutions
• Conduct quality assurance testing related to reporting systems, data integrity, and analyses
• Coordinate efforts to improve team engagement with dashboards
• Promote efficient reporting practices across Transitions to Community Living (TCL)
• Analyze Transition to Community Living Requirements and Translate into Specifications
• Develop report requests and business specifications
• Conduct research to gain a better understanding of data requirements for TCL projects
• Validate data in reports and presentations with business owners and department/unit leadership prior to delivery
• Design products that merge data from various sources
• Assist TCL with data assurance/integrity efforts required as part of larger quality activities
• Collaborate with department/unit leadership to develop processes and definitions for data collection and reporting details
• Ensure that reporting activities correspond with externally mandated specifications
• Perform quality checks

TCL Analyst, Evaluation Coordinator

• 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.
• Collaborate with other community systems to work in partnership to support the identified population.
• Complete comprehensive assessments or Care Needs Screening at enrollment, yearly or at changes in condition.
• Develop Plans of Care derived from the completed assessments.
• Demonstrate commitment to whole person/integrated care.
• Assign interventions/plans of care to applicable Alliance Care Management team member to meet identified member needs, for monitoring, and/or service engagement activities.
• Submit referrals to the Transition Coordinator when a physical health or behavioral health need indicates medical and/or pharmaceutical complexity.
• Assist individuals/legally responsible persons in choosing service providers; ensuring objectivity in the process; ensuring objectivity in the process.
• Consistently evaluate appropriateness of services and ensure implementation of plan of care through information gathering and assessment at defined frequency of contact based on risk stratification.
• Actively collaborate with members/legally responsible person, care team, service providers, and identified supports to ensure development of a plan that accurately reflects the individual’s needs and desired life goals including collaborating with residential placement search in conjunction with internal team members or external stakeholders as needed.
• Verify accuracy of demographic information with member. Update inaccurate information from the Global Eligibility File following documented protocols.
• Provide education and support, to individuals and LRP, in learning about and exercising rights, explanation of the grievance and appeals process, available service options, providers available to meet their needs, and payer requirements that may impact service connection and maintenance.
• Verify that ongoing service adherence is maintained through monitoring meetings with member and/or provider.

• Under general guidance of the Quality Management Director, continuously improve Alliance’s quality related strategies
• Manage a diverse team of performance specialists and clinical quality data analysts
• Review and analyze complex quality data sets for improvement opportunities
• Lead high-risk, complex priority initiatives as a trusted thought partner to QM leadership
• Facilitate evidence-based clinical quality interventions to improve member care and outcomes
• Oversee team project management activities including data gathering and analysis
• Ensure accountability practices for measuring team efficacy
• Advise and consult internal and external stakeholders at all organizational levels
• Conduct internal quality assurance audits and reviews as assigned

Manager, Quality Performance

Full-stack Engineer

• Responsible for building and leading a Software Architecture Team
• Define, develop, and enforce best practices, processes, policies and system security
• Identify, define, and develop internal business applications, interfaces, and other projects
• Work with Human Resources and the Sr. Director to attract, maintain, and retain a highly qualified and well-trained workforce
• Ensure staff are well trained and comply with all organization and department policies, procedures, and business processes
• Organize workflows and ensure staff understand their roles and responsibilities
• Ensure the department has the needed tools and resources to achieve organizational goals
• Establish and promote a positive, diverse, and inclusive working environment
• Recommend solutions and/or best practices in the architecture, design, security, and governance of the Alliance technology environment
• Act as a bridge between development and operations teams to ensure alignment on architectural goals
• Conduct code reviews and ensure adherence to coding standards and best practices

Manager, Software Architecture

• Assures that individuals and families with special health care needs receive integrated whole-person-person centered care management, including coordinating across physical health, behavioral health, pharmacy and unmet health-related resource needs.
• Complete comprehensive assessments or Care Needs Screening at enrollment, yearly or at changes in condition
• Develop Plans of Care derived from the completed assessments
• Demonstrate commitment to whole person/integrated care
• Assign interventions/plans of care to applicable Alliance Care Management team member to meet identified member needs, for monitoring, and/or service engagement activities
• Complete required Screening Tools
• Retrieve and review historical data to better-understand member’s treatment history
• Submit referrals to the Transition Coordinator when a physical health or behavioral health need indicates medical and/or pharmaceutical complexity
• Assign Plan of Care activities to Community Health Worker if member has identified Social Determinants of Health (SDOH), disparities and/or complex payer issues
• Assist individuals/legally responsible persons (LRP) in choosing service providers, ensuring objectivity in the process
• Consistently evaluate appropriateness of services and ensure implementation of plan of care through information gathering and assessment at defined frequency of contact based on risk stratification
• Utilize person centered planning, motivational interviewing and historical review of assessments in JIVA to gather information and to identify supports needed for the individual
• Assist in collecting data to be used to identify and address barriers as well as determine the effectiveness of care management/care coordination in reducing lengths of stay and use of emergency services
• Actively collaborates with members/legally responsible person, care team, service providers, and identified supports to ensure development of a plan that accurately reflects the individual’s needs and desired life goals
• Submits required documentation to UM to ensure timely delivery of services - and trouble shoot until authorization is obtained.
• Notify a member’s care team and providers of successful authorization (for residential or waiver related services)
• For Medicaid C, enlist administrative support to send Level of Care (LOC) and initial Individual Service Plan (ISP) to Department of Social Services (DSS) to turn on special waiver program indicator.
• Verify that necessary Client, Employer, Group (CEG) enrollments are correct in JIVA, and that Medicaid eligibility is updated in Alliance Claims System
• Schedule initial contact with member for purpose of assessment and engagement
• Verify accuracy of demographic information with member. Update inaccurate information from the Global Eligibility File following documented protocols
• Schedule face to face, virtual, and telephonic meeting with member/guardian to provide education about Alliance Health Plan, care teams, resources, and services
• Provide education and support, to individuals and LRP, in learning about and exercising rights, explanation of the grievance and appeals process, available service options, providers available to meet their needs, and payer requirements that may impact service connection and maintenance
• Refer members who are in crisis/institutional setting and require assistance with returning to community based services to the Integrated Health Consultant or applicable care team member

Care Manager I – Waiver

• Assures that individuals and families with special health care needs receive integrated whole-person care management
• Coordinates across physical health, behavioral health, pharmacy and unmet health-related resource needs
• Collaborates with other community systems to work in partnership to support the identified population
• Completes comprehensive assessments or Care Needs Screening at enrollment, yearly or at changes in condition
• Develops Plans of Care derived from the completed assessments
• Assigns interventions/plans of care to applicable Alliance Care Management team member to meet identified member needs
• Submits referrals to the CCM when a physical health or behavioral health need indicates medical and/or pharmaceutical complexity
• Assists individuals/legally responsible persons in choosing service providers; ensuring objectivity in the process
• Consistently evaluates appropriateness of services and ensures implementation of plan of care

Care Manager I - TCL

• Provide supervision and oversight to clinically licensed Care Managers and Qualified Professional Care Managers.
• Oversee staff conducting assessment of member needs.
• Link members to network and community resources.
• Develop and monitor the implementation of plans of care.
• Address barriers interfering with member’s desired outcomes.
• Travel within the communities Alliance serves as needed.

Supervisor II – Care Managers

Artificial Intelligence

• Lead a team of data professionals responsible for driving the development and implementation of AI/ML solutions
• Manage and develop staff, ensuring productivity and success in meeting assigned objectives
• Collaborate with cross-functional teams to design, build, and deploy AI/ML models
• Oversee the collection, processing, and analysis of large datasets from various sources
• Develop best practices, processes, and policies to ensure alignment with corporate strategy and goals
• Advise executive and senior leadership on complex strategic and operational IT initiatives
• Communicate corporate initiatives effectively to both technical and non-technical stakeholders

Director – Artificial Intelligence

Bilingual

• Conduct Initial Screenings, Assessments, and Reviews, and make referrals
• Receive escalated calls from Member & Recipient Service Representatives
• Callers may be actively psychotic, actively suicidal, actively homicidal, intoxicated, in active withdrawal and/or experiencing a medical emergency
• Make clinical triage decisions based on often limited information obtained during telephonic screening
• Ensure individuals receive a comprehensive screening and appropriate referral
• Maintain safety of all callers
• Engage Decision to Warn when working with callers with active homicidal ideation, according to policy
• Report to Child Protective Services and Adult Protective Services, when warranted
• Identify high risk/special health care needs populations and refer to Care Coordination
• Review caller history in the client management system
• Use electronic scheduling system to schedule and secure assessment appointments
• Complete specialized screening documentation for all service-related calls
• Document all incoming call activity in MCO tracking system
• Monitor incoming fax system and overflow vendor reports

Bilingual Behavioral Health Crisis Clinician

• Responsible for supporting the policy analysis, writing and research activities
• 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
• Shaping healthcare policies that address critical challenges and promote equitable and efficient healthcare delivery
• Supporting documents management activities within the Clinical Planning and Policy team
• Conducting qualitative research
• Designing medical necessity criteria to ensure medically appropriate services
• Communicating current trends to internal and external stakeholders
• Reviewing state developed clinical coverage policies
• Facilitating activities related to the Medical Policy Committee meetings
• Developing and implementing adequate work plans for project improvement activities

Clinical Planning and Policy Analyst

• Manage the quality review process for provider-led care management programs
• Conduct quality reviews and audits of provider-led care management programs and processes
• Analyze Care Management Documentation and Activities to Ensure Compliance
• Review the quality of provider-led Care Management programs by completing administrative and clinical case reviews
• Audit provider-led Care Management policy and procedures, staffing, training, and provision of all Care Management activities
• Analyze program data to identify trends and develop corrective action plans

External Clinical Quality Analyst I

Operations

• Coordinate with internal teams and external partners to ensure timely, informed, and seamless care transitions.
• Manage inbound and outbound communications related to transition planning, data accuracy, and care coordination.
• Pull, analyze, and interpret transition data to identify needs, assign follow-up tasks, and support care planning.
• Proactively identify and resolve transition-related issues to minimize care gaps and enhance member outcomes.
• Process and document incoming warm handoffs for members transitioning from other health plans to Alliance.
• Maintain and update key transition data for all members moving between health plans and PLEs; prepare and submit monthly and quarterly reports.
• Accurately document all activities in Jiva and other designated care management systems.
• Analyze transition-related data to identify trends and opportunities for improving interagency communication and care coordination.

Encounter Analyst I

Supervisor – Accounting

Claims Research Analyst

HEDIS Data Analyst

Encounter Analyst II

Provider Network Helpdesk EVV Specialist

Supervisor – Business Intelligence (BI) Analyst

Complex Care Consultant, OT

Care Manager I – Non-Waiver

Care Manager II

TCL Analyst, Evaluation Coordinator

Care Manager I – Non-Waiver

Manager, Quality Performance

Manager, Software Architecture

Care Manager I – Waiver

Care Manager I - TCL

Supervisor II – Care Managers

Director – Artificial Intelligence

Bilingual Behavioral Health Crisis Clinician

Clinical Planning and Policy Analyst

External Clinical Quality Analyst I

Transition Support Operations Coordinator