Clinical Quality and Regulatory Specialist

Description

:

GENERAL OVERVIEW:

Assures the highest standards of clinical quality and regulatory compliance across Utilization Management department activities for all 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 all 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 contracts, 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 oversight of policies and procedures to support regulatory requirements related to Case Management.
• Develops and implements appropriate audit requirements in order to ensure compliance with all staff activity related 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 corporate tools and processes to effectively monitor individual staff and overall department compliance, including but not limited to: conducting complex 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, complex processes and action plans to division/unit staff, corporate partners, and external customers.
• Facilitate and lead 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 within 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 Oversight

• Monitors delegated entity on a routine basis and obtains or prepares periodic reports, as needed, for management, the Delegation Oversight 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 develop recommendations to correct, which may include a formal corrective action plan.
• Provides delegate with clear expectations of requirements as a result of various regulations, contracts, and corporate initiatives.
• Serves as department point person for specific delegated entities as assigned.

6. Other duties as assigned or requested.

III. QUALIFICATIONS:

Education, Licenses/Certifications, and Experience

Minimum

• Current license in one or more of the following disciplines: LCSW, LSW, LPC, or other related clinical license (OR) Current State of PA RN licensure OR Current 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 Microsoft Office products
• 3 or more years’ experience working in the health care/health 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 all 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 perform in a fast paced, and often intense environment
• Excellent written and verbal communication skills
• Ability to analyze data, measure outcomes and develop action plans
• Be enthusiastic, innovative and flexible.
• Team player that possesses strong analytical and organizational skill
• 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

Pay Range Minimum:

$50,200.00

Pay Range Maximum:

$91,200.00

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

We endeavor to make this site accessible to any and all 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