Clinical Quality and Regulatory Specialist

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

📋 Description

• Assist in ensuring compliance within Health Services, encompassing Appeals and Grievances, Case Management, Utilization Management, and Medical Pharmacy.

• Work in collaboration with Health Services leadership and the Compliance team on regulatory and delegated responsibilities.

• Create and execute internal audits.

• Conduct routine and ad-hoc monitoring of Health Services operations.

• Oversee delegation of vendors and subcontractors.

• Review utilization-management decision-making staff monthly for adherence to clinical policies and processing timeframe compliance.

• Coordinate with Health Services, Compliance, and Fraud, Waste, and Abuse teams to detect, report, and investigate cases.

• Stay updated on Federal, State, organizational, and industry regulations, standards, best practices, and State contract language.

• Evaluate, interpret, and communicate the impacts of new and revised regulations; provide necessary training.

• Address compliance-related inquiries from both internal and external auditors.

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

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

• Utilize LEAN methodologies and quality-improvement principles, visual boards, and daily huddles to track KPIs and identify enhancements.

• Review and update policies, procedures, reference materials, training resources, member and provider communications, and handbooks.

• Facilitate education and onboarding programs for employees, vendors, and subcontractors.

• Provide backup support, participate in committees and task groups, and represent Health Services as needed.

• Adhere to privacy policies and HIPAA regulations; perform additional duties as assigned.

⛳️ Requirements

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

• Minimum of 2 years of experience in the insurance industry is required.

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

• Current unrestricted state license(s) are required.

• Within 2 years in this role, obtain Certified Case Manager (CCM) certification accredited by CCMC, or complete 60 CEUs in Utilization Management focus areas.

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

• Understanding of health insurance and State-mandated benefits along with contractual benefits is necessary.

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

• Awareness of patient confidentiality, privacy, and health records security is crucial.

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

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

• Proficient in reading and understanding written and spoken English.

• Strong communication skills, both verbal and written.

• Approximately 10% travel is required.

🏝️ Benefits

• Within 2 years in this position, obtain Certified Case Manager (CCM) as accredited by CCMC, or 60 CEUs in Utilization Management areas of focus.

• Access to employee education, onboarding, and continued education programs.

• Commitment to equal opportunity employment and a focus on diversity, equity, and inclusion.

• Work in a general office environment equipped with ergonomically designed equipment.