UM Compliance Specialist

Job Summary

The UM Compliance Specialist supports the Utilization Management (UM) Program, delegated reporting deliverables, and regulatory requirements for Imperial Health Plan / Imperial Health Holdings Medical Group (IHP/IHHMG). This position assists with NCQA Accreditation preparation and ongoing FDR compliance oversight, ensuring UM operations meet CMS, NCQA, DHCS, DHMC Knox-Keene requirements, and Health Plan standards.

Essential Job Functions

• Serve as the UM Compliance Specialist liaison with Delegated Health Plan partners for ongoing UM reporting deliverables.
• Support monitoring of delegated UM activities for compliance with CMS, NCQA, DHCS, and Health Plan requirements.
• Aid in the development and maintenance of UM policies, procedures, UM Program Description, and UM Work Plan.
• Track and maintain required UM reporting calendars, deliverables, and data sources.
• Audit Support
• Assist in the organization, coordination, and submission of documents for UM audits (Health Plan, CMS, DHCS, NCQA, internal audits).
• Manage and maintain the UM audit repository and master audit dashboard.
• Track audit findings, CAP responses, and follow-up activities through resolution.
• NCQA Accreditation Support
• Assist with planning and implementing NCQA Accreditation activities, including:
• Mock Survey preparation and readiness checks.
• Managing NCQA Survey repositories and maintaining NCQA document standards (annotation, bookmarking, version control).
• Managing the IRT web-based survey tool, uploading documents, and generating required reports.
• Developing stakeholder agendas, training materials, and distributing communications related to NCQA readiness.
• Creating best-practice toolkits, training, and reference resources for internal teams.
• Training & Education
• Oversee Annual UM Training for UM staff and physician reviewers, including roster maintenance and documentation tracking.
• Support development of training materials for UM processes, audit readiness, accreditation requirements, and regulatory updates.
• Partner with internal teams to coordinate training sessions, track attendance, and monitor completion status.
• Administrative & Project Support
• Schedule UM meetings, regulatory audit meetings, and project-related sessions.
• Prepare agendas, take meeting minutes, and track status updates for UM initiatives and projects.
• Aid in preparation of presentations/reports for Medical Services, QI Sub-Committees, UM governance, and NCQA workgroups.
• Stakeholder & Member Support
• Act as a resource to staff, providers, and/or members for UM program information and compliance-related inquiries.
• Support communication flow between UM, Compliance, CM, Population Health, and external partners.
• Compliance, Attendance & Conduct
• Adhere to payroll/timekeeping policies with minimal manual edits.
• Maintain regular and reliable attendance.
• Follow all IHHMG policies, including Compliance Plan, HIPAA regulations, and Standards of Conduct.

Marginal Job Functions

• Perform special projects as assigned.
• Other duties as needed to support UM and Compliance operations.

Behavioral Expectations

• Continuous Learning
• Attend department meetings, trainings, workshops, and seminars as required.
• Customer Focus
• Maintain confidentiality and privacy in alignment with HIPAA and IHHMG Standards of Conduct.
• Foster professional communication with supervisors, coworkers, providers, and members.
• Quality / Process Improvement
• Report safety, security, or compliance concerns promptly.
• Demonstrate adherence to policies, procedures, and regulatory standards.

Position Requirements

• Education / Experience
• High school diploma or equivalent required.
• Bachelor’s Degree or equivalent combination of education.
• PREFERRED: 2–3 years of experience in managed care, utilization management, quality, compliance, or accreditation for a Medicare Advantage and/or Medi-Cal plan or delegated medical group.
• Skills / Knowledge / Abilities
• Strong planning, organizational, and time-management skills.
• Ability to manage multiple tasks and changing priorities.
• Excellent communication skills (written, verbal).
• Ability to maintain confidentiality and professional conduct.
• Skilled in judgment, decision-making, and problem-solving.
• Ability to understand and comply with Federal, State, and local regulations.
• Proficiency with computer systems and tracking tools (e.g., audit repositories, survey tools, UM systems).