Alliance Health

General

• Recruit providers to ensure an adequate network of providers
• Manage assigned recruitment projects and resources
• Collaborate with the Provider Relations team and create strategies for network growth
• Assist in recruiting and retaining qualified providers
• Plan and execute daily recruitment call schedules and approaches
• Use network reports to identify network gaps and recruit providers so networks remain competitive and compliant with state and federal regulations
• Track and report recruitment interactions and cycle stages using application tracking mechanisms
• Compile internal data to determine network needs and increase the network
• Maintain professional relationships with the provider community
• Act as the point of contact for providers
• Provide technical assistance and customer service to network providers, other departments, and external stakeholders
• Research and troubleshoot issues while collaborating with other departments
• Participate in assigned committees and meetings, providing feedback based on market conditions, industry trends, and provider insights
• Research, identify, and negotiate contracts within established timelines
• Maintain knowledge of assigned provider contracts in conjunction with Finance and Contract departments

Provider Relations Specialist

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
• 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 Support Team when a physical health or behavioral health need indicates medical and/or pharmaceutical complexity
• Assign Plan of Care activities to Transition Support Team if member has identified Social Determinants of Health (SDOH), disparities and/or complex payer issues
• Schedule initial contact with member for purpose of assessment and engagement
• Schedule face to face, virtual, and telephonic meeting with member/guardian to provide education about Alliance Health Plan, care teams, resources, and services

Care Manager I – Non-Waiver

Clinical Specialist

• Assesses the medical necessity of services
• Independently conduct medical necessity reviews of service requests
• Ensure authorized services address service needs, intensity of service outcomes, and alternatives for consumers
• Conduct pre-certification, concurrent, and retrospective reviews to ensure compliance
• Conduct utilization reviews to monitor adherence to clinical practice guidelines
• Notify members of adverse benefit determinations while preserving members’ Due Process rights
• Ensure compliance with performance measures outlined within all accrediting body standards

UM Clinical Specialist, RN – Physical Health

Evaluator

• Plan, design, implement, conduct, and report program evaluations.
• Ensure consistent delivery of services with funding requirements and regulations.
• Utilize qualitative and quantitative evaluation methods.
• Interpret and analyze data using statistical techniques.
• Review and synthesize existing research to inform service decisions.
• Develop, design, and implement evaluation projects based on valid research methods.
• Acquire and analyze data from primary and secondary sources.
• Evaluate quality of services and analyze provider outcomes.
• Prepare reports documenting findings and recommendations.
• Assist in developing instructional materials related to evaluation studies.

Clinical Service Evaluator II

Consultant

• Provide Care Team Support
• Support members transitioning from institutional care settings to community-based care
• Provide subject matter expertise, within scope, regarding member’s physical and/or behavioral health to support the development and delivery of a whole person approach to Care Management
• Work collaboratively with other Alliance staff, behavioral health providers, primary care physicians, specialty care providers and other community partners and stakeholders to support members in their home communities
• Complete Assessments and Planning
• Utilize person-centered planning, motivational interviewing, and assessments to gather information and care planning
• Address concern(s) and/or questions from internal CM staff about the physical health/treatment/medications for our members
• Educate team members about impact of member’s health conditions on service engagement, clinical outcomes, and prognosis
• Actively collaborate with member and care team members to ensure care plan accurately reflects the individual’s clinical needs and desired life goals
• Collaborate with our internal Care Management staff and provide consultation regarding members with specialized physical health needs, transitions between care settings, and physical health needs identified via the assessments and care plan generation
• Provide medication reconciliation and education
• Consult with Pharmacy Team for Polypharmacy concerns as appropriate
• Provide Physical Health Consultation to Internal Care Management team members for questions related to member’s Physical Health (i.e., CHF, Diabetes)
• Medication Management
• The Physical Health Consultant will process and prioritize referrals from Care Management staff to ensure a medication reconciliation is completed
• Contact via phone or email the member and/or guardian to schedule an appointment to review member’s medications
• Review of members medical history to identify risk factors including recent hospitalizations, emergency room visits, seeing more than one physician, polypharmacy, or any new diagnoses
• Connect with members at scheduled appointment times via telephone or virtually
• Review and address Medication Adherence barriers
• Consult and escalate cases to Alliance’s Pharmacy team according to process and standard procedure
• Documentation
• Ensure all clinical documentation (e.g. goals, plans, progress notes, etc.) meet state, agency, and Medicaid requirements
• Follow administrative procedures and effectively manages caseload
• Data
• Review, validate and interpret risk stratification data and population health groups and recommend changes or adjustments to care management approach as needed
• Utilize data to analyze needs of the members we serve, guide staff training development, identify resource needs and consistency of workflow implementation across disciplines

Care Management Consultant

• The Care Manager II position leads all communication among care team members and is the primary point of contact for the member served.
• 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.
• Schedule initial contact with member to verify accuracy of demographic information.
• Communicate with member to check on status, verify care needs are met and that no new clinical needs warrant a change in condition assessment.
• Promote customer satisfaction through ongoing communication and timely follow-up on any concerns/issues.
• Ensure all clinical documentation meets state, agency documentation standards, and Medicaid requirements.

Care Manager II

• Conduct Assessments and Planning
• Assist the treatment team with members transitioning to the community from institutional care settings to community-based care
• Utilize person-centered planning, motivational interviewing and assessments to review information and develop rapport with the members supported
• Provide education to the individual/legal guardian on the behavioral health, physical health, and other recommended services
• Ensure compliance with all DOJ Settlement requirements and adhere to best practice standards for assessments and treatment planning
• Convene and facilitate transition meetings to ensure that a person’s housing, clinical activity needs, and issues related to health and safety are identified and addressed on a timeline

TCL Transition Coordinator

• Conduct Assessments and Planning
• Assist the treatment team with members transitioning to the community from institutional care settings to community-based care
• Utilize person-centered planning, motivational interviewing and assessments to review information and develop rapport with the members supported
• Obtain necessary releases of information that will improve care management activities on behalf of the member
• Provide education to the individual/legal guardian on the behavioral health, physical health, and other recommended services based on Comprehensive Clinical Assessment (CCA) including how these services will be part of the of resources to support the individual in residing in supportive housing.
• Ensure that assessments and plans are updated, as needed, whenever the members’ life circumstances change
• Complete Administrative assessments/ plans of care for the needs identified in the assessments and complete the interventions identified as needed
• Ensure compliance with all DOJ Settlement requirements and adhere to best practice standards for assessments and treatment planning
• Coordinate and Lead Community Transitions
• Review BH crisis plans and care plans to ensure the presence of integrated care interventions and these plans reflect the needs and desires of members
• Ensure that all team members and stakeholders involved with members are aware of how to train, manage and mitigate crisis events, behavioral and physical, that the member may experience
• Ensure referrals to RN/OT Evaluator Team when there are physical health and/or significant functional health concerns noted in the CCA
• Assist persons with identifying initial and rehousing housing options based on preferences and needs and discuss barriers to housing
• Ensure financial supports needed for the individual is addressed with the Transition Team and in the PCP
• Convene and facilitate transition meetings to ensure that a person’s housing, clinical activity needs, and issues related to health and safety are identified and addressed on a timeline
• In-person visits as defined by the settlement
• Intervene to preserve tenancy and avoid housing separations, and evaluate tenancy issues to extend housing tenure
• Ensure health and safety monitoring needs of the TCL members are addressed
• Escalate high risk/high visibility and/or complex barriers/needs members who may have SDOH/Behavioral/Physical needs to high-risk committee
• Promote customer satisfaction through ongoing communication and timely follow-up on any concerns/issues that include face to face member visits as outlined in DHHS Transition manual
• Ensure compliance with all DOJ Settlement requirements including the comprehensive core responsibilities outlined in the DHHS In Reach/Transition and Diversion manual
• Distribute surveys to members who are receiving services
• Verify that initial service linkage is completed through monitoring of activities in JIVA
• Verify members Medicaid and promptly follow up on identified issues.
• Monitor and ensure the provision of community services for at least 90 days post transition emphasizing tenancy stability.
• Resolve any conflict or inadequate care with provider
• Follow all TCL policies and procedures
• Maintain Documentation
• Ensure all documentation (e.g. goals, plans, progress notes, etc.) meet state, organization, and Medicaid requirements
• Monitor documentation to ensure that issue/errors are resolved
• Follow administrative procedures and effectively manage caseload
• Ensure timely documentation into state required TCL platforms
• Travel
• Travel between Alliance offices, attending meetings on behalf of Alliance, participating in Alliance sponsored events, etc. may be required
• Travel to meet with members, providers, stakeholders, attend court hearings etc. is required

• Manage the leave administration process to include communication and coordination with employees, supervisors, payroll and third-party vendor throughout the process
• Monitor and track leaves related to FMLA, ADA, paid parental leave, short-term/long-term disability, and unpaid leaves to verify start and end dates and ensure communication with supervisors, payroll, and third-party vendor
• Manage accommodation request process including facilitating the interactive process, evaluating medical documentation, case management, and consistent communication to applicable parties and timely issuance of decisions and due process rights
• Advise managers and employees on the interaction of leave laws and procedural requirements with paid and unpaid time off, workers compensation, and short-term and long-term disability benefits
• Maintain consistent communication throughout leave process to ensure information is shared timely and appropriately with employees and supervisors to facilitate smooth and timely return to work
• Provide appropriate notices to employees during and at the end of leaves
• Oversee the return-to-work process for employees returning from FMLA, ADA, or other medical leave(s) to ensure applicable documentation is obtained and filed appropriately
• Effectively interpret FMLA and ADA implications as they relate to leave of absences and disability requests in consultation with Legal
• Collaborate with payroll to ensure employees are paid accurately while on leave of absence and benefits payments are recouped appropriately for employees on unpaid leave
• Collaborate with Employee Relations and Legal as needed on any potential employee issues or legal concerns
• Maintain knowledge of all applicable leave and accommodation laws including the FMLA, ADA, and state and local laws
• Maintain complete and accurate records of leave and accommodation requests in accordance with specified legal requirements and documentation of best practices
• Manage creating, reviewing, and updating all leave resources
• Create and conduct trainings for staff and supervisors regarding FMLA and ADA processes
• Assist with audits including carrier and leave audits, as well as benefit reporting
• Assist with coordination of benefit related events including setup and monitoring
• Assist with performing quality checks of leave-related data
• Provide process improvement recommendations and suggestions that align with the goals of the Benefits team and Alliance
• Serve as backup for Benefits Specialist and Manager when needed
• Assist with Benefits email box and respond to or escalate inquires appropriately
• Perform related tasks as required

Leave Specialist

Analyst

• Provides clinical direction, guidance, training, and quality oversight for clinical aspect of Healthcare Effectiveness Data and Information Set (HEDIS)
• Oversees abstraction, overreads and quality analysis of HEDIS for both Prospective and Retrospective Seasons
• Ensures compliance with the standards set by NCQA and CMS
• Performs quality improvement activities to monitor/maintain quality of care and compliance
• Coordinates HEDIS data collection, medical record review, and quality improvement activities
• Participates in the development, research, and implementation of HEDIS improvement activities
• Analyzes and interprets technical specifications, business requirements, and regulatory guidance to support accurate implementation of HEDIS measures
• Coordinates and oversees all quality management programs/projects ensuring compliance with regulations

HEDIS Clinical Quality Analyst

• Conduct targeted member outreach related to health promotion, wellness, chronic condition management, maternal and child health, substance use, tobacco prevention and other population health initiatives using telephone, member portal, text, email, mail, and related modalities.
• Provides education on benefits available through Alliance and its network to address unmet member healthcare needs.
• Refers members to Care Coordination, Care Management and primary care as needed.
• Collaborates on development of member-focused education and training needs, curricula and educational initiatives.
• Enhances cross-functional collaboration, promotes access to essential services and analyzes emerging trends to support continuous quality improvement.
• Proactive and targeted outreach using phone, text, portal messages, email, and mail.
• Updates member contact information and communication preferences in Jiva.
• Explains benefits and services in a clear, compassionate, and culturally responsive manner.
• Identifies barriers to care and acts as a liaison with internal teams to resolve barriers to preventive care.
• Provides information, education, and consultation to organizations serving individuals with special health needs or high-risk populations.

Health Promotion and Outreach Specialist

Medical Director

• Provide expert guidance and oversight for physical health service requests
• Ensure the integrity and quality of utilization management activities
• Participate in internal reviews of inpatient and outpatient clinical case types
• Apply medical necessity criteria utilizing review criteria hierarchy
• Complete expected case volume as expected by the department
• Follow department processes as defined by approved Alliance policies
• Support the Clinical Operations Department through active participation in organizational committees
• Provide clinical guidance and leadership to promote collaboration between medical, behavioral, and care management teams
• Maintain awareness of regulatory requirements, utilization management guidelines, and emerging trends
• Contribute to process improvement initiatives aimed at enhancing clinical quality, efficiency, and member outcomes
• Support cross functional teams with medical expertise
• Train and mentor peers within the Medical Management team

Medical Director – Physical Health

• Analyze Care Management documentation and activities to ensure compliance
• Review the quality-of-Care Management internal processes/plans and provider information, such as Person-Centered Plans or chart notes, for alignment with procedures and/or best practices
• Audit Care Management clinical documentation, case interventions, and, if available, staff phone recordings to ensure alignment with program descriptions, workflows, internal policies, evidence based clinical guidelines, NCQA guidelines, CMS guidelines, and regulatory guidelines (when applicable)
• Identify and escalate situations which may pose quality, compliance, and safety risks that may adversely affect business operation
• Evaluate clinical appropriateness of decisions, recommendations, and actions within Care Management documentation
• Interpret qualitative and quantitative information to appropriately document findings
• Make recommendations for improvement related to any records reviewed and write reports of findings
• Identify system and/or operational issues hindering the attainment of quality performance standards as defined by NCQA standards, applicable state and Federal laws and regulations
• Analyze Data and Report on findings
• Generate monthly Care Management Quality reports on Staff performance to submit to Directors, Managers, and Supervisors
• Provide written feedback to Directors, Managers and Supervisors concerning quality concerns pertaining to individual performance, compliance risks/trends, root cause analysis and any system or process improvements recommended
• Evaluate knowledge gaps of staff and coordinate training
• Evaluate knowledge gaps of the staff and collaborate with Care Management Leadership to coordinate learning and training opportunities with the Care Management Training team
• Monitor training of staff for effectiveness and impact of outcomes from enhanced training

Clinical Quality Analyst

• Oversee the development, implementation, and support of EDI systems, processes and vendor interactions
• Collaborate with cross-functional teams, manage EDI projects, and ensure seamless electronic data exchange with partners and customers
• Lead and manage the EDI development and support team, providing guidance, mentorship, and technical expertise
• Oversee the design, development, and implementation of EDI solutions
• Collaborate with IT, operations, and business analysts to gather requirements
• Manage EDI projects from initiation to completion
• Coordinate with external trading partners to establish EDI connections
• Develop and maintain EDI maps, transformations, and data mappings
• Ensure the reliability, availability, and security of EDI systems
• Provide technical expertise and support to resolve complex EDI-related issues
• Prepare and present regular reports and updates to IT management

Manager, EDI Development and Support

• Assures that individuals and families with special health care needs receive integrated whole-person care management
• Coordinate across physical health, behavioral health, pharmacy, and unmet health-related resource needs
• Link to services and supports to maximize outcomes and decrease unnecessary use of hospitals
• Collaborate with community systems 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
• Assign interventions/plans of care to applicable Alliance Care Management team member
• Submit referrals to the Transition Support Team when necessary
• Assist individuals/legally responsible persons in choosing service providers
• Evaluate appropriateness of services and ensure implementation of plan of care
• Utilize person centered planning and motivational interviewing to gather information
• Schedule initial contact with member for assessment and engagement
• Verify accuracy of demographic information and schedule meetings with member/guardian
• Provide education and support to individuals and LRP
• Recognize and report critical incidents and provider quality concerns