Clinical Quality and Regulatory Specialist

Location: Remote in PA, WV, or working from home in Pennsylvania or West Virginia

About the role

Assures that all department activities are compliant with regulatory guidelines and agencies, including but not limited to: NCQA, CMS, DPW, and DOH. Supports the integration of new vendors and lines of business, including processes, procedures, risk identification, education, and delegation follow-up. Manages the oversight, development, and maintenance of case management policies and procedures to ensure accreditation and compliance with CMS and DPW requirements. Works closely with other departments to resolve issues and align activities with Case Management processes. Provides consultation to the department, monitors regulatory changes, industry trends, and contract changes, and educates staff and management as needed.

Responsibilities

• Regulatory Compliance
  • Manages and coordinates department activities, including policy and procedure development, staff audits, and operations to ensure compliance with standards and regulations.
  • Develops and implements modifications to workload plans to ensure completion.
  • Provides service support, training, and performance metrics to the team, initiating process improvements.
  • Identifies and escalates issues appropriately, applying clinical knowledge to policy and process development.
  • Conducts audits, monitors noncompliance, and reports to management, corporate compliance, or audit personnel.
  • Contributes to the development of corrective action plans and implements them with management.
  • Researches federal and state regulations, business requirement contracts, and subcontracted delegated entities.
  • Gathers information and prepares reports for regulatory agencies or internal customers.
• Quality Assurance
  • Reviews and provides input on policies and procedures to support regulatory requirements for Case Management.
  • Develops and implements audit requirements to ensure compliance with staff activities.
  • Performs internal clinical and non-clinical audits for quality assurance and regulatory compliance.
  • Creates and implements corporate tools and processes to monitor staff and department compliance.
  • Recommends and develops corrective action plans for management, overseeing implementation.
• Communication
  • Maintains consistent communication with internal and external customers.
  • Communicates changes in processes and programs to enhance shared vision and mission.
  • Effectively communicates outcomes, data analysis, complex processes, and action plans to staff, partners, and customers.
  • Facilitates and leads informational and educational meetings.
  • Demonstrates excellent interpersonal, verbal, and written communication skills.
  • Collaborates across departments.
• Project Management
  • Accountable for special projects and enhanced activities within the department.
  • Participates in the development and implementation of department/division projects.
  • Involved in integration processes and planning activities.
  • Coordinates and facilitates workgroups.
  • Supports the integration of new lines of business as assigned.
• Delegation Oversight
  • Monitors delegated entities routinely and prepares periodic reports for management or regulatory agencies.
  • Identifies risks and develops plans to minimize organizational impact.
  • Identifies issues with delegates and develops recommendations or corrective action plans.
  • Provides delegates with clear expectations based on regulations, contracts, and corporate initiatives.
  • Serves as the department point person for specific delegated entities.
• Other duties as assigned or requested.

Requirements

• Current license in one or more of the following disciplines: LCSW, LSW, LPC, or other related clinical license OR current State RN licensure OR current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).
• 3-5 years’ experience in case management/managed care with specific knowledge of quality monitoring, compliance, and/or regulatory processes.
• 2 years’ experience with quality measurement systems.
• 1 year’s experience evaluating, implementing, or revising work processes.

Qualifications (Preferred)

• Bachelor’s degree.
• 3+ years’ experience performing auditing/monitoring functions.
• 3+ years’ experience creating tools, training documents, and educational materials for adult learners.
• 3+ years’ experience with Microsoft Office products.
• 3+ years’ experience in the healthcare/health insurance industry.
• Quality Management System certification.

Skills

• Experience in workforce development and resource management with excellent team-building and professional development skills.
• Strong leadership, collaboration, and motivational skills.
• Ability to multi-task and perform in a fast-paced, intense environment.
• Excellent written and verbal communication skills.
• Ability to analyze data, measure outcomes, and develop action plans.
• Enthusiastic, innovative, and flexible.
• Strong analytical and organizational skills.
• Ability to prioritize work demands and meet deadlines.
• Excellent computer and software knowledge and skills.

Pay

Pay Range Minimum: $62,700.00
Pay Range Maximum: $97,200.00
Base pay is determined by a variety of factors including qualifications, experience, expected contributions, internal peer equity, market, and business considerations. Geographic differentials may apply for certain locations.

Schedule

Full time

Work Environment

• Travel is required.
• This role does not supervise or manage other employees.