Clinical Quality and Regulatory Specialist

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🔥 1 hour ago

🔔 Pennsylvania, Virginia, +1 more states – Remote

🔔 Pennsylvania – Remote ⚔️ Virginia – Remote ⛰️ West Virginia – Remote

💵 $62.7k - $97.2k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🚔 Compliance

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Highmark Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1852

🛡️ Insurance

💼 Consulting

📦 Logistics

💰 $5M Grant on 2021-05

Insurance • Consulting • Logistics

Highmark Health is a healthcare company committed to reinventing the healthcare system and improving its services for everyone. The organization offers a broad range of career opportunities across various fields such as clinical care, technology, finance, and marketing. Highmark Health emphasizes diversity, equity, and inclusion in its workforce, creating a supportive environment for employees from all backgrounds. The company has been recognized for its commitment to disability inclusion, diversity, and military-friendly employment. As an independent licensee of the Blue Cross Blue Shield Association, Highmark Health strives to create remarkable healthcare experiences for its customers and employees alike.

📋 Description

• Assure department activities comply with NCQA, CMS, DPW, DOH, and other regulatory guidelines • Support integration of new vendors and lines of business, including processes, procedures, risk identification, education, and delegation follow-up • Manage oversight, development, and maintenance of case management policies and procedures • Monitor regulatory changes, industry trends, and contract changes • Educate staff and management through formal and informal training • Coordinate policy and procedure development and revision, staff audits, workload plans, service support, training, performance metrics, and process improvements • Conduct audits, monitor and report noncompliance, and contribute to and implement corrective action plans • Research federal and state regulations, Medicaid bulletins, CMS coverage determinations, contracts, and delegated-entity materials • Gather information and prepare reports for regulatory agencies and internal customers • Develop and implement audit requirements and quality-assurance processes for Case Management • Create and implement corporate tools and processes to monitor staff and department compliance • Communicate outcomes, data analysis, complex processes, and action plans to internal and external stakeholders • Facilitate informational and educational meetings • Participate in department projects, integration planning, workgroups, and implementation activities • Monitor delegated entities, identify risks and issues, prepare reports, and develop recommendations or corrective action plans • Perform other duties as assigned

🎯 Requirements

• Current license in one or more of: 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/managed care with specific knowledge of quality monitoring, compliance, and/or regulatory processes • 2 years of experience with quality measurement systems • 1 year of experience evaluating, implementing, or revising work processes • Preferred: Bachelor’s degree • Preferred: 3 or more years of experience performing auditing/monitoring functions • Preferred: 3 or more years creating tools, training documents, and educational materials for adult learners • Preferred: 3 years of experience with Microsoft Office products • Preferred: 3 or more years in the health care/health insurance industry • Preferred: Quality Management System certification • Experience in workforce development and resource management • Staff/project management experience • Leadership, collaboration, and motivational skills • Ability to multitask in a fast-paced environment • Excellent written and verbal communication skills • Ability to analyze data, measure outcomes, and develop action plans • Strong analytical and organizational skills • Ability to prioritize work and meet deadlines • Excellent computer and software knowledge and skills • Travel is required • Must comply with HIPAA, data-security guidelines, the company Code of Business Conduct, applicable laws, regulations, policies, and training requirements