Clinical Quality and Regulatory Specialist

PacificSource•Bend, OR

1d•$70,950 - $106,425

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, and maintains working knowledge of applicable federal, state, industry, organizational, and contractual requirements. The specialist conducts and participates in audits, investigates potential issues and improvement opportunities, and helps maintain compliant policies, procedures, member and provider materials, and employee resources. The position also supports employee education and orientation programs for Health Services staff, vendors, and subcontractors. It prepares and presents required regulatory and organizational reports, responds to auditor inquiries, participates in committees and meetings, and promotes continuous improvement using LEAN and quality improvement practices. The work is performed in a general office setting with ergonomically configured equipment, with travel required approximately 10% of the time.

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, such as Licensed Professional Counselor, Licensed Marriage and Family Therapist, or Psychiatric Mental Health Nurse Practitioner.
Thorough knowledge of medical procedures, diagnoses, care modalities, procedure codes including ICD-10, DSM-IV, and CPT, 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 tools and concepts across teams within 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 as part of a team.
Skills in accountability, collaboration, written and verbal communication, flexibility, active listening, organization and planning, problem solving, and teamwork.
Ability to meet the described physical requirements, including stooping and bending, sitting or standing for extended periods, repetitive motions, and light lifting and carrying.
Ability to read and comprehend written and spoken English and communicate clearly and effectively.

Nice To Haves

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 in Utilization Management areas of focus.

Responsibilities

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