Clinical Compliance Coordinator (Remote)

Highmark Health

5d•Remote

About The Position

JOB SUMMARY This job is responsible for working with HHO clinical departments in the areas of compliance and process improvement. Serves as a corporate resource regarding accreditation standards, clinical performance and continuous improvement principles. Manages the oversight and development of clinical submissions for regulator inquiries. Oversees development and maintenance of Care Management policies and procedures to ensure accreditation and compliance with NCQA and DMMA requirements. Monitors regulatory changes, industry trends, and contract changes on an ongoing basis. Conducts analysis and oversight of design, development, modification, adaptation, implementation and execution of solutions for improvement of short-term and long-term clinical and operational excellence. Collaborates with various organizational leaders to prepare briefings or reports and conduct data analyses.

Requirements

5 years of experience as working in a clinical setting.
3 years of experience as case management/managed care (with specific knowledge of quality monitoring, compliance and/or regulatory processes)
1 year of experience in evaluating, implementing or revising work processes
Workforce development and resource management with excellent team building and professional development skills
Strong leadership, collaboration, and motivational skills
Staff/project management
Ability to relate to all levels of management and staff as well as individuals external to the corporation
Ability to multi task and perform in a fast paced, and often intense environment
Excellent written and verbal communication skills
Ability to analyze data, measure outcomes and develop action plans
Be enthusiastic, innovative and flexible.
Ability to prioritize work demands and meet deadlines
Excellent computer and software knowledge and skills
Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC), LCSW, LSW, LPC or related clinical licensure, Within 45 days of hire.

Nice To Haves

3 years of experience in performing auditing/monitoring functions.
3 years of experience in creating tools, training documents and educational materials geared to adult learners.
3 years of experience in healthcare/health insurance industry.
Bachelor’s degree in business, health care administration, nursing, or other related program.

Responsibilities

Serve as an internal project lead to ensure alignment and consistency in the organization's contractual clinical performance measurement across Care Management.
Manage and coordinate department activities including but not limited to: policy and procedure development and revision, individual staff audits, and overall operations to ensure compliance to standards and regulations.
Serve as the point of contact and Highmark Health Options clinical representative to state regulators.
Continuously examine processes and procedures to identify opportunities for improvement and refinement.
Perform internal clinical audits for the purpose of quality assurance, and to assure compliance with respect to regulatory requirements and corporate policies/procedures.
Recommend and develop corrective action plans to management.
Oversee final plan implementation and communication.
Effectively communicate outcomes, data analysis, complex processes and action plans to division/unit staff, corporate partners across departments and external customers.
Research federal and state regulations and other regulatory materials, various business requirement contracts and subcontracted delegate entity to ensure compliance.
Coordinate department accreditation, oversight and compliance activities with regulatory guidelines/agencies, including but not limited to NCQA and DMMA.
Other duties as assigned or requested.