Sr Psychologist-I/DD (Full-time Remote, North Carolina Based)

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 & DutiesClinical Oversight & Medical ReviewProvide 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/DDConduct 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 toolsEnsure the integrity and quality of UM activities, including initial reviews, concurrent reviews, appeals, and level of care determinations for inpatient and outpatient servicesParticipate in internal case reviews to ensure compliance with regulatory, accreditation, and organizational standardsEvaluate complex cases involving I/DD and other residential services, co-occurring conditions, and members with disabilities requiring ADA-aligned accommodations or alternative care pathwaysReview 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 serviceReview 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 membersProvide consultation to UM staff and community providers regarding service eligibility criteria, clinical documentation standards, and regulatory complianceReview 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 authorizationProvide Staff Consultations Provide consultation and education services to staff as needed regarding best practices, clinical guidelines, and evidence-based treatmentsProvide 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 individualsProvide clinical case consultation and guide the care management of outlier casesProcess 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 efficientlyMaintain accuracy of clinical documentation and uphold audit readinessProvide clinical consultation to UM department in efforts to identify over/underutilization patterns and participate in analysis of practice patternsParticipate in quality improvement initiatives, including reviewing trend analysis, service gaps, and policy enhancementsEnsure that services delivered under NC Medicaid, LME/MCO, and other requirements meet clinical, operational and quality standardsOperational & 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 CommitteesProvide clinical guidance and leadership to promote collaboration between physical health, behavioral health, and care management teamsAssist with development of clinical guidelines, approval criteria, and UM decision support toolsEngage 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 HearingsParticipate in appeal-related mediation activities and Office of Administrative Hearing (OAH) processes as required, providing clinical expertise and documentation supportParticipate in court hearings to provide expert testimony during court proceedings to suggest or validate treatment recommendationsAnalyze data and make recommendations for Quality Improvement Identify over/under utilization patterns and participate in analysis of practice patternsReview consumer records to assess employee compliance with established rules, regulations, and appropriate clinical practicesAssist 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 necessaryImplement audits, corrective action plans, and quality assurance initiativesAdditional Responsibilities Maintain awareness of regulatory requirements, utilization management guidelines, and emerging trends affecting utilization management and behavioral health servicesContribute to process improvement initiatives aimed at enhancing clinical quality, efficiency, and member outcomesSupport cross-functional teams with medical expertise, as neededProvide consultation, training, and education to staff and community partners on relevant topics as neededTrain and mentor peers within the Medical Management team and assist with onboarding other new hires as neededMinimum RequirementsEducation & ExperienceRequired: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, & AbilitiesKnowledge 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 measuresKnowledge of managed care practices and principlesKnowledge of recent developments in the field of psychology and I/DD in particularThorough knowledge of theories and practices in the field of psychologyThorough knowledge of the causes, dynamics, and effects of psychopathological patterns of behaviorThorough knowledge of the principles of psychotherapeutic interventions and psychotherapyKnowledge of a wide range of objective and projective psychological assessments, tools, and techniques for specific and comprehensive evaluationsAdvanced experience in applying, interpreting, and communicating assessments and treatment techniquesConsiderable knowledge of community resourcesConsiderable knowledge of the laws, regulations, and policies that govern the program and its functionsKnowledge of State and Federal rules and requirements and practices related to the service continuum in North CarolinaMicrosoft Office skillsExcellent communication and interpersonal skillsAbility to express ideas clearly and concisely and to plan and execute work effectively and independentlyAbility to formulate an assessment of need, to set as a plan of action, and to think through the process and act expedientlyAbility to provide clinical supervision to advanced level cliniciansKnowledge of NC Medicaid policies, Tailored Plan contractual obligation, and ADA compliance and other federal standardsAbility to support high-quality care coordination, member advocacy, consistent, timely, and equitable review practicesProvide 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/AnnuallyExact 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 DisabilityGenerous retirement savings planFlexible work schedules including hybrid/remote optionsPaid time off including vacation, sick leave, holiday, management leaveDress flexibilityEqual Opportunity EmployerThis employer is required to notify all applicants of their rights pursuant to federal employment laws.