Clinical Compliance Program Manager

WellSky

72d

About The Position

This job is responsible for ensuring compliance with WellSky's Utilization Management and Quality Improvement Program by serving as a clinical expert on state and federal regulations. The scope of this job includes analyzing and presenting data to establish best practices across post-acute health care settings, including LTACHs, IRFs, SNFs, and Home Health facilities. We invite you to apply today and join us in shaping the future of healthcare!

Requirements

• At least 4-6 years relevant work experience.
• Advanced working knowledge of CMS UM audits.
• At minimum, 2-3 years of compliance experience focused on CMS and health plan audits.
• At minimum, 1-2 years of implementing CMS final rule changes and managing change management of processes.
• Bachelor's Degree or equivalent work experience.

Nice To Haves

• Active, unrestricted license: RN, PT, OT or SLP, with a bachelor’s degree in a related field or a combination of education and experience that includes pertinent clinical experience and advanced working knowledge of CMS standards and guidelines.
• Experience with NCQA audits.
• Must be able to prioritize, plan and handle multiple tasks and demands simultaneously, with competing deadlines.
• Excellent in manipulating and sorting data for analytics and reporting.
• Prior experience owning client compliance SLAs and ensuring success in meeting SLA requirements.

Responsibilities

• Facilitate activities related to performance measurement and outcomes.
• Ensure the organization meets CMS, NCQA, and other regulatory standards.
• Stay updated on relevant regulatory changes and support their integration into practices.
• Comply with state, federal, and organizational standards by assisting in the development and enforcement of policies aligned with Utilization Management and Quality Improvement Program requirements.
• Complete and successfully submit CMS reports: ODAG, Part C, Reopening, and Complaints and Grievance Reports.
• Conduct Root Cause Analysis (RCA) with Operational teams.
• Conduct regular compliance audits based on CMS UM standards for expedited, standard and other case statuses.
• Develop and guide the implementation of internal audit protocols in compliance with CMS regulations and NCQA standards.
• Contribute to the consistency of clinical documentation and decision-making processes.
• Generate and validate reports to monitor performance and compliance across health plan contracts, ensuring accuracy and alignment with requirements.
• Prepare for regulatory, accreditation, and contractual audits, and contribute to the remediation and documentation of audit findings.
• Perform other job duties as assigned.

Benefits

• Excellent medical, dental, and vision benefits.
• Mental health benefits through TelaDoc.
• Prescription drug coverage.
• Generous paid time off, plus 13 paid holidays.
• Paid parental leave.
• 100% vested 401(K) retirement plans.
• Educational assistance up to $2500 per year.

What This Job Offers

• Job Type: Full-time
• Education Level: Bachelor's degree
• Number of Employees: 1,001-5,000 employees