Clinical Quality and Regulatory Specialist
About The Position
The Clinical Quality and Regulatory Specialist supports compliance across Health Services, including Appeals and Grievances, Case Management, Utilization Management, and Medical Pharmacy. The role monitors and reports on Health Services operations and delegated functions, collaborates with Health Services leadership and Compliance on regulatory oversight, and maintains working knowledge of applicable federal, state, industry, organizational, and contractual requirements. The specialist conducts and participates in audits, investigates potential issues, identifies improvement opportunities, and helps maintain compliant policies, procedures, member and provider materials, and employee resources. The position also supports development and maintenance of employee education and orientation programs for Health Services staff, vendors, and subcontractors. It prepares and presents required reports, responds to auditor inquiries, participates in committees and meetings, and promotes continuous improvement using LEAN and quality improvement practices. The role is based 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 healthcare exposure.
- At least two years of insurance industry experience.
- Current unrestricted state license as a Registered Nurse, Licensed Clinical Psychologist, Licensed Clinical Social Worker, or comparable behavioral health professional with extensive experience and/or credentials.
- Thorough knowledge of medical procedures, diagnoses, care modalities, procedure codes including ICD-10, DSM-IV, and CPT codes, health insurance, and state-mandated benefits.
- Knowledge 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-record security.
- Ability to apply strategy deployment, daily operations, visual management, operational improvement, and auditing tools and concepts.
- 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.
- Ability to meet the physical requirements of stooping and bending, extended sitting and/or standing, repetitive typing, sorting and filing, and light lifting and carrying of files and business materials.
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 for compliance with applicable rules, regulations, and standards.
- Perform routine and ad hoc monitoring of Health Services operations and report findings to leadership, Compliance, and relevant committees.
- Conduct delegation oversight of vendors and report on regulatory compliance and service agreement performance.
- Monitor staff, vendors, and subcontractors involved in utilization management decision-making at least monthly for consistent application of clinical policies and compliance with processing timeframes.
- Serve as a liaison between Health Services, Compliance, and Fraud, Waste, and Abuse teams to identify, report, and, when assigned, investigate FWA cases.
- Maintain knowledge of applicable requirements and provide assessments, interpretations, impact reports, and training on new or revised rules and requirements.
- Collaborate with Health Services leadership, regulatory and reporting staff, and Compliance to respond to compliance-related inquiries from internal and external auditors.
- Oversee, prepare, present, and submit required reports to government 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.
- Use LEAN methodologies and quality improvement principles, visual boards, and daily huddles to monitor performance indicators and identify improvement opportunities.
- Monitor, create, and revise internal documents and materials, including policies, procedures, desk references, training materials, letters, and handbooks, to support compliance and branding alignment.
- Support implementation and maintenance of employee, vendor, and subcontractor education and onboarding programs covering operational and regulatory requirements.
- Provide backup for other Health Services staff as needed and within scope of licensure.
- Serve on designated committees, teams, and task groups; represent Health Services internally and externally as requested.
- Meet department and company performance and attendance expectations.
- Follow company privacy policy and HIPAA requirements for confidentiality and security of protected health information.
- Perform other duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
