The Sr Psychologist – I/DD is a licensed professional who brings both clinical and health plan experience in intellectual and developmental disability (I/DD) to the Alliance Medical Management team, primarily performing utilization management (UM) activities (e.g., peer reviews, appeals) for requested services commonly used by Alliance members with I/DD, such as Research-Based Behavioral Health Treatment (RB-BHT) for Autism Spectrum Disorder (ASD) and services provided under the 1915(i) and Innovations Waivers, and secondarily as an internal subject matter expert (SME) on I/DD.
This position is fulltime remote. Selected candidate must reside in North Carolina. Some travel for onsite meetings to the Home office at Morrisville may be required.
Responsibilities & Duties
Clinical Oversight & Medical Review
- Provide Peer Review (second level review) to determine the medical necessity of authorization for services requested under NC Medicaid and relevant Waivers, particularly those utilized by Alliance members with I/DD
- Conduct initial, concurrent, and retrospective reviews using NC Medicaid Clinical Coverage Policies, nationally recognized criteria (e.g., MCG), Tailored Plan-specific benefit guidance, and other approved UM tools
- Ensure the integrity and quality of UM activities, including initial reviews, concurrent reviews, appeals, and level of care determinations for inpatient and outpatient services
- Participate in internal case reviews to ensure compliance with regulatory, accreditation, and organizational standards
- Evaluate complex cases involving I/DD and other residential services, co-occurring conditions, and members with disabilities requiring ADA-aligned accommodations or alternative care pathways
Review Approval and Denial of Service, Level of Care Requests, and Service Eligibility
- Apply medical necessity criteria utilizing review criteria hierarchy for level of care and services regarding type, amount, and duration of service
- Review and determine clinical appropriateness of certain residential settings and services. Assess clinical appropriateness, step-up/step-down pathways, length-of-stay, and transition planning for complex, high-needs, and high-acuity members
- Provide consultation to UM staff and community providers regarding service eligibility criteria, clinical documentation standards, and regulatory compliance
- Review crisis assessments and evaluations to determine service eligibility and treatment placement. Assist in reviewing behavioral healthcare/person-centered plans as part of Utilization Review to assure that services are prescribed that are consistent with presenting problems and have been provided in accordance with the person-centered plan and service authorization
Provide Staff Consultations
- Provide consultation and education services to staff as needed regarding best practices, clinical guidelines, and evidence-based treatments
- Provide routine clinical case staffing to assist in the identification of high-risk and other special health care need populations; provide clinical case consultation to ensure accurate assessment of these individuals
- Provide clinical case consultation and guide the care management of outlier cases
Process Adherence, Quality & Efficiency
- Follow department processes, as defined by approved Alliance policies, desk procedures, and workflows, to complete timely utilization reviews in Alliance’s UM platform and perform tasks efficiently
- Maintain accuracy of clinical documentation and uphold audit readiness
- Provide clinical consultation to UM department in efforts to identify over/underutilization patterns and participate in analysis of practice patterns
- Participate in quality improvement initiatives, including reviewing trend analysis, service gaps, and policy enhancements
- Ensure that services delivered under NC Medicaid, LME/MCO, and other requirements meet clinical, operational and quality standards
Operational & Committee Support
- Serve as clinical representative on various committees and workgroups as deemed appropriate by departmental leadership, including but not limited to those involving case discussions, clinical rounds, appeals, and the Medical Policy, Quality, and Utilization Management Committees
- Provide clinical guidance and leadership to promote collaboration between physical health, behavioral health, and care management teams
- Assist with development of clinical guidelines, approval criteria, and UM decision support tools
- Engage with Provider Network Development in the development of new services and on provider reviews/audits (when requested)
Participate in the development of Alliance’s benefit plan
External Engagement Including Court Hearings
- Participate in appeal-related mediation activities and Office of Administrative Hearing (OAH) processes as required, providing clinical expertise and documentation support
- Participate in court hearings to provide expert testimony during court proceedings to suggest or validate treatment recommendations
Analyze data and make recommendations for Quality Improvement
- Identify over/under utilization patterns and participate in analysis of practice patterns
- Review consumer records to assess employee compliance with established rules, regulations, and appropriate clinical practices
- Assist with inter-rater reliability studies for clinical departments including selection of cases for study, and development of clinical vignettes, and provide follow-up training as necessary
- Implement audits, corrective action plans, and quality assurance initiatives
Additional Responsibilities
- Maintain awareness of regulatory requirements, utilization management guidelines, and emerging trends affecting utilization management and behavioral health services
- Contribute to process improvement initiatives aimed at enhancing clinical quality, efficiency, and member outcomes
- Support cross-functional teams with medical expertise, as needed
- Provide consultation, training, and education to staff and community partners on relevant topics as needed
- Train and mentor peers within the Medical Management team and assist with onboarding other new hires as needed
Minimum Requirements
Education & Experience
Required:
Graduation from an accredited doctoral program in psychology with PhD or PsyD degree and at least three (3) years of relevant postgraduate clinical experience required. Experience with services commonly used by the I/DD population required, including RB-BHT for ASD.
Current, active, and unrestricted license to practice psychology (LP) as well as behavior analysis (LBA) in North Carolina required.
Preferred:
• Experience with managed care and utilization management strongly preferred, ideally within NC Medicaid, LME/MCO, or Tailored Plan environments.
• Familiarity with services provided under the 1915(i) and Innovations Waivers preferred.
Knowledge, Skills, & Abilities
- Knowledge of the information and techniques needed for diagnosis and treatment of behavioral health and I/DD issues, including symptoms, treatment and residential settings, and preventive healthcare measures
- Knowledge of managed care practices and principles
- Knowledge of recent developments in the field of psychology and I/DD in particular
- Thorough knowledge of theories and practices in the field of psychology
- Thorough knowledge of the causes, dynamics, and effects of psychopathological patterns of behavior
- Thorough knowledge of the principles of psychotherapeutic interventions and psychotherapy
- Knowledge of a wide range of objective and projective psychological assessments, tools, and techniques for specific and comprehensive evaluations
- Advanced experience in applying, interpreting, and communicating assessments and treatment techniques
- Considerable knowledge of community resources
- Considerable knowledge of the laws, regulations, and policies that govern the program and its functions
- Knowledge of State and Federal rules and requirements and practices related to the service continuum in North Carolina
- Microsoft Office skills
- Excellent communication and interpersonal skills
- Ability to express ideas clearly and concisely and to plan and execute work effectively and independently
- Ability to formulate an assessment of need, to set as a plan of action, and to think through the process and act expediently
- Ability to provide clinical supervision to advanced level clinicians
- Knowledge of NC Medicaid policies, Tailored Plan contractual obligation, and ADA compliance and other federal standards
- Ability to support high-quality care coordination, member advocacy, consistent, timely, and equitable review practices
- Provide clinical leadership, medical review, and regulatory oversight for integrated physical and behavioral health services with a focus on I/DD
Employment for this position is contingent upon a satisfactory background check, which will be performed after acceptance of an offer of employment and prior to the employee's start date.
Salary Range
$101,764 - $129,749/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 and Short 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