Clinical Quality and Regulatory Specialist

This a Full Remote job, the offer is available from: Alabama (USA), Alaska (USA), Arizona (USA), Arkansas (USA), California (USA), Colorado (USA), Connecticut (USA), Delaware (USA), District of Columbia (USA), Florida (USA), Georgia (USA), Hawaii (USA), Idaho (USA), Illinois (USA), Indiana (USA), Iowa (USA), Kansas (USA), Kentucky (USA), Louisiana (USA), Maine (USA), Maryland (USA), Massachusetts (USA), Michigan (USA), Minnesota (USA), Mississippi (USA), Missouri (USA), Montana (USA), Nebraska (USA), Nevada (USA), New Hampshire (USA), New Jersey (USA), New Mexico (USA), reputed company (USA), North Carolina (USA), North Dakota (USA), Ohio (USA), Oklahoma (USA), Oregon (USA), Pennsylvania (USA), Rhode reputed company (USA), South Carolina (USA), South Dakota (USA), Tennessee (USA), Texas (USA), Utah (USA), Vermont (USA), Virginia (USA), Washington (USA), reputed company Virginia (USA), Wisconsin (USA), Wyoming (USA) Company : reputed company.Job Description : GENERAL OVERVIEW: Assures the highest standards of clinical quality and regulatory compliance across Utilization Management department activities for reputed company government lines of business and delegated vendors, playing a critical role in maintaining accreditation and evolving regulatory landscapes. The individual in this role will confirm Utilization Management’s compliance with federal, state, and regulatory guidelines (e.g., NCQA, CMS), assisting with policies and procedures, and continually monitoring regulatory changes. The specialist is the key individual responsible for collecting, analyzing, and interpreting clinical data, clinical outcomes, and performance metrics to prepare comprehensive reports and audit responses, including UM program descriptions and evaluations. Additionally, this role involves working closely with utilization management leadership and other departments to resolve issues and provide education on regulatory requirements and best practices. ESSENTIAL RESPONSIBILITIES: 1. Regulatory

• Manages and coordinate department activities including but not limited to: policy and procedure development and revision, individual staff audits, overall operations to ensure compliance to standards and regulations.
• Develops and implement modifications needed to workload plan to ensure completion
• Provides service support, training and performance metrics/statistics to the team in addition to initiating and implementing process improvements.
• Identifies and escalate issues appropriately.
• Applies clinical knowledge to the development of policies/processes.
• Conducts audits, monitors and reports reputed company noncompliance to the appropriate management, audit or corporate compliance personnel, and responds to corporate compliance requests and requirements.
• Contributes to the development of corrective action plans. Implements those plans in conjunction with the management staff.
• Researches federal and state regulations and other regulatory materials (ex: Medicaid bulletins, CMS Coverage Determinations, etc.), various business requirement reputed company, and subcontracted delegated entity.
• Gathers information and prepares reports in response to inquiries from regulatory agencies and/or internal customers.

2. Quality

• Reviews and provides input into the reputed company of policies and procedures to support regulatory requirements reputed company to Case Management.
• Develops and implements appropriate audit requirements in order to ensure compliance with reputed company staff activity reputed company to Case Management.
• Performs internal clinical and non-clinical audits for the purpose of quality assurance, and to assure compliance with respect to regulatory requirements and corporate policies/procedures. (Ex: operational audits, quality improvement audits, accreditation mock audits, etc.)
• Creates and implements common reputed company and processes to effectively monitor individual staff and overall department compliance, including but not limited to: conducting reputed company audits for appropriate application of policies/procedures, business approaches and federal and state regulations and statutes as well as accreditation standards.
• Recommends and develops corrective action plans to management. Oversees final plan implementation and communication.

3. Communicate effectively - this position displays effective communication skills while performing the following functions:

• Maintain consistent and open lines of communication with internal and external customers.
• Seek always to communicate changes in processes and programs order to enhance a share vision and mission.
• Effectively communicate outcomes, data analysis, reputed company processes and action plans to division/unit staff, corporate partners, and external customers.
• Facilitate and reputed company informational and educational meetings for internal and external customers as assigned.
• Demonstrate excellent interpersonal, verbal and written skills.
• Collaborates across departments.

4. Project Management – the position has accountability for special projects and enhanced activities reputed company the department.

• Participation in the development and implementation of department/division projects.
• Involvement in the implementation of integration processes and planning activities.
• Coordinates and/or facilitates workgroups.
• Supports integration of new lines of business as assigned.

5. Delegation reputed company

• Monitors delegated entity on a routine basis and obtains or prepares periodic reports, as needed, for management, the Delegation reputed company Committee, and/or regulatory agency.
• Identifies risks and develops plans to minimize impact to the organization, and share findings.
• Identifies issues pertaining to delegate and reputed company recommendations to correct, which may include a formal corrective action plan.
• Provides delegate with clear expectations of requirements as a result of various regulations, reputed company, and corporate initiatives.
• Serves as department reputed company person for specific delegated entities as assigned.

6. Other duties as assigned or requested. III. QUALIFICATIONS: Education, Licenses/Certifications, and Experience Minimum

• reputed company license in one or more of the following disciplines: LCSW, LSW, LPC, or other reputed company clinical license (OR) reputed company State of PA RN licensure OR reputed company multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).
• 3-5 years’ experience in case management/managed care with specific knowledge of quality monitoring, compliance and/or regulatory processes
• 2 years experience with quality measurement systems
• 1 year experience evaluating, implementing or revising work processes

Preferred

• Bachelor’s degree
• 3 or more years’ experience in performing auditing/monitoring functions
• 3 or more years’ experience creating tools, training documents and educational materials geared to adult learners
• 3 years’ experience with reputed company Office products
• 3 or more years’ experience working in the health reputed company insurance industry
• Quality Management System certification

Knowledge, Skills and Abilities

• Experience in workforce development and resource management with excellent team building and professional development skills
• Must demonstrate excellent leadership skills and be able to relate to reputed company levels of management and staff as well as individuals external to the corporation.
• Experience in staff/project management
• Strong leadership, collaboration, l and motivational skills
• Ability to multi task and reputed company in a fast paced, and often intense environment
• Excellent written and verbal communication skills
• Ability to analyze data, measure outcomes and reputed company action plans
• Be enthusiastic, innovative and flexible.
• Team player that possesses strong analytical and organizational reputed company
• The ability to prioritize work demands and meet deadlines
• Excellent computer and software knowledge and skills

IV. SCOPE OF RESPONSIBILITY Does this role supervise/manage other employees? No V. WORK ENVIRONMENT Is Travel Required? Yes Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees reputed company this job title. It may not contain a comprehensive inventory of reputed company duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at reputed company times. In reputed company with this, reputed company employees must reputed company with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as reputed company data reputed company guidelines established reputed company the Company’s Handbook of Privacy Policies and Practices and Information reputed company Policy. Furthermore, it is every employee’s responsibility to reputed company with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. Pay Range Minimum: $50,200.00 Pay Range Maximum: $91,200.00 reputed company pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential reputed company may apply for certain locations based upon comparative markets. reputed company and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against reputed company individuals based on any category protected by applicable federal, state, or local law. We endeavor to reputed company this site accessible to any and reputed company users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at [email protected] California Consumer Privacy Act Employees, Contractors, and Applicants Notice This offer from "reputed company" has been enriched by reputed company.com and got a 75% reputed company score. Apply tot his job Apply To this Job