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 operational activities and delegated functions, works with Health Services leadership and Compliance on regulatory oversight, and maintains working knowledge of applicable laws, regulations, standards, and contract language. The specialist participates in audits, identifies and follows up on potential issues and improvement opportunities, and helps maintain compliant policies, procedures, letters, materials, and employee resources. The position also contributes to employee onboarding and continuing education on operational and regulatory requirements. It uses quality improvement principles and LEAN methodologies to monitor performance, communicate key indicators, and promote continuous improvement. The work is performed inside 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, such as an LPC, LMFT, 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 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 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 with a team as appropriate.
- Skills in accountability, collaboration, written and verbal communication, flexibility, active listening, organization and planning, problem solving, and teamwork.
- Ability to stoop and bend, sit and/or stand for extended periods, perform repetitive typing, sorting, and filing, and lift and carry files and business materials.
- 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 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 committees.
- Oversee delegated vendor functions to assess regulatory compliance and performance against service agreements; report findings to leadership and committees.
- 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 among Health Services, Compliance, and Fraud, Waste, and Abuse teams to identify, report, and, when assigned, investigate potential cases.
- Maintain knowledge of applicable contract language, rules, regulations, standards, and best practices; assess and communicate the impact of new and revised requirements and provide training.
- Coordinate timely, professional, and accurate responses to compliance-related inquiries from internal and external auditors.
- 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 key performance indicators and identify and evaluate improvement opportunities.
- Monitor and revise policies, procedures, reference materials, training materials, member and provider communications, and handbooks to support regulatory compliance and organizational branding.
- Support implementation and maintenance of employee, vendor, and subcontractor education and onboarding on operational and regulatory requirements.
- Provide backup for other Health Services staff as needed and within licensure scope.
- Serve on designated committees, teams, and task groups, and represent Health Services when requested by the Medical Director or leadership.
- Meet department and company performance and attendance expectations.
- Follow 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
