Clinical Quality and Regulatory Specialist

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🔥 2 minutes ago

🍑 Georgia – Remote

🍑 Georgia – 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 • Collaborate with Health Services leadership and Compliance on regulatory and delegated functions • Develop and conduct internal audits • Perform routine and ad hoc monitoring of Health Services operations • Perform delegation oversight of vendors and subcontractors • Monitor utilization-management decision-making staff at least monthly for clinical-policy consistency and processing-timeframe compliance • Liaise with Health Services, Compliance, and Fraud, Waste, and Abuse teams to identify, report, and investigate cases • 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; 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, visual boards, and daily huddles to monitor KPIs and identify improvements • Monitor and revise policies, procedures, references, training materials, member and provider letters, and handbooks • Support employee, vendor, and subcontractor education and onboarding programs • Provide backup support, serve on committees and task groups, and represent Health Services as requested • Follow privacy policy and HIPAA requirements; perform other duties as assigned

🎯 Requirements

• A minimum of six years nursing or clinical behavioral health experience with varied health care exposure and experience required • A minimum 2 years insurance industry experience required • 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) • Within 2 years in this position, obtain Certified Case Manager (CCM) as accredited by CCMC, or 60 CEUs in Utilization Management areas of focus • Thorough knowledge and understanding of medical procedures, diagnoses, care modalities, ICD-10, DSM-IV, and CPT Codes • Knowledge of health insurance and State-mandated benefits and contractual 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 • 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 • Approximately 10% travel 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 • Employee education, onboarding, and continuing education programs • Equal opportunity employment and commitment to diversity, equity, and inclusion • General office setting with ergonomically configured equipment

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