Provider Network Evaluator I-Targeted Monitoring (Full-time Remote, North Carolina Based)

The PNE Targeted Reviewer I is responsible for conducting focused and targeted reviews that may include health and safety reviews, quality of care issues, intensive incident report reviews, the appropriateness of clinical services delivered by providers in the Alliance network. The PNE Targeted Reviewer I is required to review claims data, clinical documentation, provider contracts, policies, and procedures, conduct provider staff and stakeholder interviews, 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 I