Clinical Quality and Regulatory Specialist

This is a fully remote position, open to applicants in Pennsylvania, +2 more states.

📋 Description

• Ensure that department operations adhere to NCQA, CMS, DPW, DOH, and other regulatory standards.

• Assist in the integration of new vendors and business lines, which includes processes, procedures, risk identification, training, and follow-up on delegation.

• Oversee the creation, development, and upkeep of case management policies and procedures.

• Keep track of regulatory amendments, industry trends, and changes in contracts.

• Provide education to staff and management through both formal and informal training sessions.

• Coordinate the development and revision of policies and procedures, conduct staff audits, create workload plans, provide service support, facilitate training, measure performance metrics, and drive process improvements.

• Perform audits, monitor and report instances of noncompliance, and assist in the development and implementation of corrective action plans.

• Investigate federal and state regulations, Medicaid bulletins, CMS coverage determinations, contracts, and materials from delegated entities.

• Compile information and generate reports for regulatory bodies and internal stakeholders.

• Design and implement audit requirements and quality-assurance processes for Case Management.

• Develop corporate tools and processes to ensure departmental and staff compliance.

• Communicate findings, data analyses, complex processes, and action plans to both internal and external stakeholders.

• Conduct informational and educational meetings.

• Engage in departmental projects, integration planning, workgroups, and implementation activities.

• Monitor delegated entities, identify risks and issues, prepare reports, and formulate recommendations or corrective action plans.

• Perform additional duties as assigned.

⛳️ Requirements

• Valid license in one or more of the following: LCSW, LSW, LPC, or another related clinical license, or current State RN licensure, or current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).

• 3–5 years of experience in case management or managed care, with a strong understanding of quality monitoring, compliance, and/or regulatory processes.

• At least 2 years of experience with quality measurement systems.

• Minimum of 1 year of experience in evaluating, implementing, or revising work processes.

• Preferred: Bachelor’s degree.

• Preferred: 3 or more years of experience in auditing or monitoring functions.

• Preferred: 3 or more years of experience creating tools, training documents, and educational materials for adult learners.

• Preferred: 3 years of experience with Microsoft Office Suite.

• Preferred: 3 or more years in the health care or health insurance sector.

• Preferred: Certification in Quality Management Systems.

• Experience in workforce development and resource management.

• Experience in staff or project management.

• Strong leadership, collaboration, and motivational abilities.

• Capability to multitask in a dynamic environment.

• Excellent written and verbal communication skills.

• Proficiency in data analysis, outcome measurement, and action plan development.

• Strong analytical and organizational skills.

• Ability to prioritize tasks and meet deadlines.

• Excellent knowledge and skills in computer systems and software.

• Travel may be required.

• Must adhere to HIPAA, data-security guidelines, the company's Code of Business Conduct, and all applicable laws, regulations, policies, and training requirements.

🏝️ Benefits

• Comprehensive health, dental, and vision insurance.

• Retirement savings plan with employer matching.

• Generous paid time off and holiday schedule.

• Opportunities for professional development and continuing education.

• Employee wellness programs and resources.