Clinical Quality and Regulatory Specialist

PacificSource•WFH: GA, GA

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 operational activities 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 participates in audits, investigates and follows up on potential issues and improvement opportunities, and helps maintain compliant policies, procedures, member and provider materials, and employee resources. The role also supports employee onboarding and continuing education on regulatory and operational requirements. The position conducts internal audits and routine or ad hoc monitoring, oversees delegated vendor functions, and monitors utilization management decision-making for consistent application of clinical policies and required processing timeframes. It coordinates responses to auditors and compliance inquiries, prepares and submits required agency and committee reports, represents Health Services in meetings and audits, and promotes continuous improvement using LEAN methods and quality improvement principles. The role contributes to education programs for employees, vendors, and subcontractors. The work is performed inside a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time. Physical requirements include stooping and bending, sitting and/or standing for extended periods, 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 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 knowledge of options available within and outside contractual benefits.
Ability to use computerized systems for data recording and retrieval.
Ability to ensure patient confidentiality, privacy, and health-record security.
Proficiency applying 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.
Ability to read and comprehend written and spoken English and communicate clearly and effectively.
Ability to meet the stated physical requirements, including extended sitting and/or standing, repetitive motions, and light lifting and carrying.

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 for compliance with applicable Federal, State, organizational, and industry requirements.
Perform routine and ad hoc monitoring of Health Services operations, and report findings to leadership, Compliance, and appropriate committees.
Conduct delegated-function oversight of applicable vendors and report findings to Health Services leadership and relevant committees.
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, when assigned, investigate FWA cases.
Maintain knowledge of applicable rules, regulations, standards, best practices, and State contract language; assess and interpret changes, report their impact, and provide training.
Coordinate timely, professional, and accurate responses 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 actively participate in assigned internal and external meetings, committees, and audits as a presenter or Health Services representative.
Use LEAN methodologies, quality improvement principles, visual boards, and daily huddles to monitor KPIs, communicate performance, and identify and evaluate improvement opportunities.
Monitor, create, or revise internal documents and materials—including policies, procedures, desk references, training materials, member and provider letters, and handbooks—to support compliance and organizational branding.
Support implementation and maintenance of employee education programs covering onboarding and continuing education for employees, vendors, and subcontractors.
Provide backup for other Health Services staff as needed and within scope of licensure.
Serve on assigned committees, teams, and task groups; represent Health Services internally and externally as requested.
Meet department and company performance and attendance expectations.
Follow PacificSource privacy policy and HIPAA requirements concerning the confidentiality and security of protected health information.
Perform other duties as assigned.