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, and maintains working knowledge of applicable Federal, State, industry, organizational, and contractual requirements. The specialist conducts and participates in audits, investigates potential issues, and follows up on opportunities for improvement. The position also helps maintain compliant policies, procedures, member and provider materials, and employee resources. In collaboration with leadership and training teams, the specialist supports employee education and onboarding on operational and regulatory requirements. The role uses quality improvement practices, including LEAN methods, visual management, and daily huddles, and represents Health Services in assigned meetings, committees, and audits. The position works inside in a general office setting with ergonomically configured equipment and requires approximately 10% travel. Physical demands include stooping and bending, extended sitting and/or standing, repetitive typing, sorting and filing, and light lifting and carrying of files and business materials.
Requirements
- At least six years of nursing or clinical behavioral health experience with varied healthcare 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-record security.
- Ability to use and implement strategy deployment, daily operations, visual management, operational improvement, and auditing tools and concepts 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 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 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 relevant internal committees.
- Perform oversight of delegated vendor functions to 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.
- Liaise with Health Services, Compliance, and Fraud, Waste, and Abuse teams to identify, report, and, as assigned, investigate FWA cases.
- Maintain current knowledge of State contract language and applicable requirements; assess and interpret new or revised requirements, report their impact, and provide training.
- Coordinate responses to compliance-related inquiries from internal and external auditors in a timely, professional, and accurate manner.
- Oversee, prepare, present, and submit required reports to Federal, State, and industry agencies and organizational committees.
- Attend and participate in assigned internal and external meetings, committees, and audits as a presenter or Health Services representative.
- Apply LEAN methodologies and quality improvement principles; use visual boards and daily huddles to monitor and communicate KPIs and identify improvement opportunities.
- Monitor and revise internal documents and materials, including policies, procedures, reference materials, training materials, and member and provider communications, to support compliance and alignment with organizational branding.
- Support the implementation and maintenance of education programs for employees, vendors, and subcontractors covering onboarding, operational requirements, and regulatory updates.
- Provide backup support for other Health Services staff as needed and within scope of licensure.
- Serve on designated committees, teams, and task groups, and represent Health Services as requested by the Medical Director and leadership.
- Meet department and company performance and attendance expectations.
- Follow PacificSource privacy policies and HIPAA requirements concerning the 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
