Clinical Quality and Regulatory Specialist

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🔥 5 minutes ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $71k - $106.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🚔 Compliance

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PacificSource Health Plans

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1933

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

PacificSource Health Plans is a healthcare provider that offers a range of health insurance solutions, including plans for individuals, families, and employers. Their offerings include Medicare and Medicaid plans, dental coverage, and administrative services for small and large groups. Committed to member care, PacificSource emphasizes customer service and provides various resources for health management, including mental health support and wellness programs.

📋 Description

• Support compliance across Health Services, including Appeals and Grievances, Case Management, Utilization Management, and Medical Pharmacy • Monitor and report on Health Services operational activities and delegated functions • Collaborate with Health Services leadership and Compliance on regulatory and delegated functions • Develop and conduct internal audits • Perform routine and ad hoc compliance monitoring and report findings • Perform delegation oversight of vendors and subcontractors • Monitor staff involved in utilization management decision-making at least monthly • Serve as liaison with Compliance and Fraud, Waste, and Abuse teams • Maintain knowledge of Federal, State, organizational, and industry rules, regulations, standards, best practices, and State contract language • Assess, interpret, and report impacts of new and revised requirements and provide training • Respond to compliance-related inquiries from internal and external auditors • Prepare, present, and submit required reports to agencies and organizational committees • Participate in internal and external meetings, committees, and audits as a presenter or Health Services representative • Apply LEAN methodologies and quality improvement principles • Use visual boards and daily huddles to monitor KPIs and identify improvement opportunities • Monitor, create, and revise policies, procedures, training materials, letters, handbooks, and other internal documents • Support employee, vendor, and subcontractor education and onboarding programs • Provide backup for other Health Services staff within scope of licensure • Serve on designated committees, teams, and task groups • Represent Health Services internally and externally • Follow privacy and HIPAA requirements and perform other assigned duties

🎯 Requirements

• Minimum of six years nursing or clinical behavioral health experience with varied health care exposure • Minimum of two years insurance industry experience • Registered Nurse; Licensed Clinical Psychologist; Licensed Clinical Social Worker; or comparable behavioral health professional with extensive experience and/or credentials • Current unrestricted state license(s) • Certified Case Manager (CCM) within 2 years, preferred, or 60 CEUs in Utilization Management areas of focus • Thorough knowledge of medical procedures, diagnoses, care modalities, ICD-10, DSM-IV, and CPT codes • Knowledge of health insurance and State-mandated benefits • Knowledge of contractual benefits and options available within and outside those benefits • Ability to use computerized systems for data recording and retrieval • Knowledge of patient confidentiality, privacy, and health records security • Proficiency in strategy deployment, daily operations, visual management, operational improvement, and auditing • Current clinical knowledge base and certification • Ability to work independently with minimal supervision and collaboratively in a team • Ability to read and comprehend written and spoken English • Ability to communicate clearly and effectively • Ability to meet performance and attendance expectations • Ability to follow PacificSource privacy policy and HIPAA laws and regulations • Travel approximately 10% of the time

🏖️ Benefits

• Certified Case Manager (CCM) certification within 2 years, preferred, or 60 CEUs in Utilization Management areas of focus • Employee education, onboarding, and continuing education programs • Equal opportunity employment • Continuous improvement and professional development opportunities • General office setting with ergonomically configured equipment

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