Clinical Quality and Regulatory Specialist

PacificSource Health Plans•Boise, ID

1d•$70,950 - $106,425

About The Position

Support all aspects of Health Services compliance, including Appeals and Grievances, Case Management, Utilization Management, and Medical Pharmacy. Monitor and report on Health Services operational activities and delegated functions, collaborating with Health Services leadership and Compliance on regulatory oversight. Maintain working knowledge of applicable Federal, State, industry, and organizational rules, regulations, standards, and contract language; conduct and participate in audits; and identify, investigate, and follow up on potential issues and opportunities for improvement. Assist with compliant policies and procedures, member and provider materials, employee resources, and education programs for onboarding and continuing education. The role works in a general office setting with ergonomically configured equipment and requires approximately 10% travel.

Requirements

At least six years of nursing or clinical behavioral health experience with varied health care exposure.
At least two years of insurance industry experience.
Registered Nurse; Licensed Clinical Psychologist; Licensed Clinical Social Worker; or comparable behavioral health professional with extensive experience and/or credentials, such as Licensed Professional Counselor, Licensed Marriage and Family Therapist, or Psychiatric Mental Health Nurse Practitioner.
Current unrestricted state license(s).
Thorough knowledge of medical procedures, diagnoses, care modalities, procedure codes including ICD-10, DSM-IV, and CPT codes, health insurance, and State-mandated benefits.
Thorough understanding of options available within and outside contractual benefits.
Ability to use computerized systems for data recording and retrieval.
Ability to protect patient confidentiality, privacy, and health records security.
Ability to use and implement strategy deployment, daily operations, visual management, operational improvement, and auditing across teams within the scope of accountability.
Ability to establish and maintain relationships with internal and external customers.
Ability to maintain current clinical knowledge and certification.
Ability to work independently with minimal supervision and collaboratively in a team.
Skills in accountability, collaboration, written and verbal communication, flexibility, active listening, organization and planning, problem solving, and teamwork.
Ability to read and comprehend written and spoken English and communicate clearly and effectively.

Nice To Haves

Demonstrated knowledge and experience with program development and auditing.
Within two years in the position, obtain Certified Case Manager (CCM) certification accredited by CCMC, or complete 60 CEUs focused on Utilization Management.

Responsibilities

Collaborate with Health Services leadership and Compliance to develop and conduct internal audits assessing compliance with applicable rules, regulations, and standards.
Perform routine and ad hoc monitoring of Health Services operations and report findings to leadership, Compliance, and appropriate internal committees.
Perform oversight of applicable vendors’ delegated functions and report findings to Health Services leadership and applicable committees.
Monitor staff, vendors, and subcontractors involved in utilization management decision-making at least monthly for consistent application of clinical policies and compliance with required processing timeframes.
Serve as a liaison among Health Services, Compliance, and Fraud, Waste, and Abuse (FWA) teams to identify, report, and, as assigned, investigate FWA cases.
Maintain knowledge of State contract language and applicable requirements; assess and interpret new and revised requirements, report their impact, and provide training.
Collaborate with leadership, regulatory and reporting staff, and Compliance to respond accurately and promptly to compliance-related inquiries from internal and external auditors.
Oversee, prepare, present, and submit required reports to Federal, State, and industry agencies and organizational committees.
Attend and participate in internal and external meetings, committees, and audits as a presenter or Health Services representative when assigned.
Apply LEAN methodologies and quality improvement principles; use visual boards and daily huddles to monitor and communicate key performance indicators and identify improvement opportunities.
Monitor, create, and revise internal documents and materials, including policies, procedures, reference materials, training materials, member and provider letters, and handbooks, to ensure compliance and alignment with organizational branding.
Support implementation and maintenance of employee education programs covering onboarding and operational and regulatory requirements for employees, vendors, and subcontractors.
Provide backup for other Health Services department staff as needed and within licensure scope.
Serve on designated committees, teams, and task groups, and represent Health Services internally and externally when requested.
Meet department and company performance and attendance expectations; follow privacy policies and HIPAA requirements for protected health information.
Perform other duties as assigned.