Clinical Quality and Regulatory Specialist

Job not on LinkedIn

🔥 20 minutes ago

🍑 Georgia – Remote

🍑 Georgia – Remote

💵 $71k - $106.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🚔 Compliance

👻 Ghost score 0%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.Why this score:

• Just posted.
• Jobs at this company usually fill in 21 days.

Apply Now

Find Similar Remote Jobs

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 functions 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 • Perform delegation oversight of vendors and subcontractors • Monitor utilization management decision-making staff at least monthly for clinical policy and processing-timeframe compliance • Liaise with Health Services, Compliance, and Fraud, Waste, and Abuse teams on FWA cases • Assess, interpret, and report impacts of new and revised rules and requirements • Respond to compliance inquiries from internal and external auditors • Prepare, present, and submit required reports to agencies and organizational committees • Represent Health Services in meetings, committees, and audits • Apply LEAN methodologies and quality improvement principles • Monitor KPIs using visual boards and daily huddles and identify improvement opportunities • Review and revise policies, procedures, training materials, member and provider communications, and handbooks for compliance • Support employee, vendor, and subcontractor education and onboarding programs • Serve as backup for other Health Services staff and participate in committees and task groups • Follow privacy policy and HIPAA requirements • Perform other duties as assigned

🎯 Requirements

• Minimum six years of nursing or clinical behavioral health experience with varied health care exposure • Minimum two years of 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) • Maintain current clinical knowledge base and certification • 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 • 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 • Travel approximately 10% of the time

🏖️ Benefits

• Equal opportunity employment • Opportunity to contribute to social justice, equity, diversity and inclusion • Employee education and continuing education programs • Certified Case Manager (CCM) certification opportunity within 2 years, or 60 CEUs in Utilization Management areas of focus • Ergonomically configured equipment • At-will employment

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume