Clinical Quality and Regulatory Specialist

This is a fully remote position, open to applicants in Florida.

📋 Description

• Provide support for compliance within Health Services, encompassing Appeals and Grievances, Case Management, Utilization Management, and Medical Pharmacy.

• Track and report on the operational activities and delegated functions of Health Services.

• Work collaboratively with Health Services leadership and Compliance on regulatory and delegated functions.

• Design and implement internal audits to ensure compliance with Federal, State, organizational, and industry standards.

• Conduct routine and ad hoc monitoring of Health Services operations, presenting findings as needed.

• Manage delegation oversight of vendors and subcontractors.

• Supervise staff and vendors involved in utilization management decision-making at least on a monthly basis.

• Act as a liaison between Health Services, Compliance, and Fraud, Waste, and Abuse teams.

• Stay informed about relevant rules, regulations, standards, best practices, and State contract language.

• Evaluate, interpret, report impacts, and train staff on new and updated requirements.

• Address compliance inquiries from both internal and external auditors.

• Compile, present, and submit necessary reports to agencies and organizational committees.

• Engage in meetings, committees, and audits as a presenter or representative of Health Services.

• Utilize LEAN methodologies and principles of quality improvement, employing visual boards and daily huddles to monitor KPIs.

• Review and update policies, procedures, training materials, letters, handbooks, and other documents for compliance and branding consistency.

• Assist in the education and onboarding programs for employees, vendors, and subcontractors.

• Serve as a backup for other Health Services personnel within the scope of licensure.

• Participate in designated committees, teams, and task groups.

• Represent Health Services internally and externally as required.

• Adhere to privacy and HIPAA regulations while performing other assigned tasks.

⛳️ Requirements

• At least six years of nursing or clinical behavioral health experience with diverse exposure to healthcare.

• Minimum of two years of experience in the insurance industry.

• Must be a Registered Nurse, Licensed Clinical Psychologist, Licensed Clinical Social Worker, or a comparable behavioral health professional with substantial experience and/or credentials.

• Possess a current unrestricted state license(s).

• Within two years of assuming this role, obtain Certified Case Manager (CCM) accreditation from CCMC, or complete 60 CEUs in Utilization Management areas of focus, preferred.

• Comprehensive knowledge of medical procedures, diagnoses, care modalities, ICD-10, DSM-IV, and CPT Codes.

• Familiarity with health insurance and State-mandated benefits.

• Capability to utilize computerized systems for data recording and retrieval.

• Understanding of patient confidentiality, privacy, and the security of health records.

• Expertise in strategy deployment, daily operations, visual management, operational improvement, and auditing.

• Ability to work independently with minimal supervision as well as collaboratively within a team.

• Proficient in reading and comprehending written and spoken English.

• Strong communication skills, both clear and effective.

• Must adhere to department and company performance and attendance standards.

• Required to comply with PacificSource privacy policies and HIPAA laws and regulations.

🏝️ Benefits

• Full-time employment opportunities.

• Work from home designation (WFH: FL).

• Professional development through employee education, orientation, and ongoing education programs.

• Opportunity to earn Certified Case Manager (CCM) certification or fulfill 60 CEUs in Utilization Management areas of focus.

• Ergonomically designed equipment.

• Commitment to equal opportunity employment and a diversity-focused workplace.

• Travel requirement of approximately 10% of the time.