Clinical Quality and Regulatory Specialist

Company :

Highmark Inc.

Job Description :

GENERAL OVERVIEW: Assures that all department activities are compliant with regulatory guidelines/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 related to ensure accreditation and compliance with CMS and DPW requirements. Works closely with other departments within the corporation to resolve issues and ensure activities coincide with Case Management processes. Provides consultation to the department. Monitors regulatory changes, industry trends, and contract changes on an ongoing basis. Educates staff and management as needed, both formal and informal. Suggests new approaches to complex [link removed] RESPONSIBILITIES: 1. RegulatoryManages and coordinate department activities including but not limited to: policy and procedure development and revision, individual staff audits, overall operations to ensure compliance to standards and [link removed] and implement modifications needed to workload plan to ensure completionProvides service support, training and performance metrics/statistics to the team in addition to initiating and implementing process [link removed] and escalate issues [link removed] clinical knowledge to the development of policies/[link removed] audits, monitors and reports all noncompliance to the appropriate management, audit or corporate compliance personnel, and responds to corporate compliance requests and requirements. Contributes to the development of corrective action plans. Implements those plans in conjunction with the management [link removed] federal and state regulations and other regulatory materials (ex: Medicaid bulletins, CMS Coverage Determinations, etc.), various business requirement contracts, and subcontracted delegated [link removed] information and prepares reports in response to inquiries from regulatory agencies and/or internal customers.2. QualityReviews and provides input into the oversight of policies and procedures to support regulatory requirements related to Case [link removed] and implements appropriate audit requirements in order to ensure compliance with all staff activity related to Case Management. Performs internal clinical and non-clinical audits for the purpose of quality assurance, and to assure compliance with respect to regulatory requirements and corporate policies/procedures. (Ex: operational audits, quality improvement audits, accreditation mock audits, etc.)Creates and implements common corporate tools and processes to effectively monitor individual staff and overall department compliance, including but not limited to: conducting complex audits for appropriate application of policies/procedures, business approaches and federal and state regulations and statutes as well as accreditation [link removed] and develops corrective action plans to management. Oversees final plan implementation and communication.3. Communicate effectively - this position displays effective communication skills while performing the following functions:Maintain consistent and open lines of communication with internal and external [link removed] always to communicate changes in processes and programs order to enhance a share vision and [link removed] communicate outcomes, data analysis, complex processes and action plans to division/unit staff, corporate partners, and external [link removed] and lead informational and educational meetings for internal and external customers as [link removed] excellent interpersonal, verbal and written [link removed] across departments.4. Project Management – the position has accountability for special projects and enhanced activities within the [link removed] in the development and implementation of department/division [link removed] in the implementation of integration processes and planning [link removed] and/or facilitates [link removed] integration of new lines of business as assigned.5. Delegation OversightMonitors delegated entity on a routine basis and obtains or prepares periodic reports, as needed, for management, the Delegation Oversight Committee, and/or regulatory [link removed] risks and develops plans to minimize impact to the organization, and share [link removed] issues pertaining to delegate and develop recommendations to correct, which may include a formal corrective action [link removed] delegate with clear expectations of requirements as a result of various regulations, contracts, and corporate [link removed] as department point person for specific delegated entities as assigned.6. Other duties as assigned or [link removed]. QUALIFICATIONS:Education, Licenses/Certifications, and ExperienceMinimumCurrent 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 processes2 years experience with quality measurement systems1 year experience evaluating, implementing or revising work processesPreferredBachelor’s degree3 or more years’ experience in performing auditing/monitoring functions3 or more years’ experience creating tools, training documents and educational materials geared to adult learners3 years’ experience with Microsoft Office products3 or more years’ experience working in the health care/health insurance industry Quality Management System certificationKnowledge, Skills and Abilities Experience in workforce development and resource management with excellent team building and professional development skillsMust demonstrate excellent leadership skills and be able to relate to all levels of management and staff as well as individuals external to the [link removed] in staff/project managementStrong leadership, collaboration, l and motivational skillsAbility to multi task and perform in a fast paced, and often intense environmentExcellent written and verbal communication skillsAbility to analyze data, measure outcomes and develop action plansBe enthusiastic, innovative and [link removed] player that possesses strong analytical and organizational skillThe ability to prioritize work demands and meet deadlinesExcellent computer and software knowledge and skillsIV. SCOPE OF RESPONSIBILITY Does this role supervise/manage other employees?NoV. WORK ENVIRONMENTIs Travel Required?YesDisclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this [link removed] Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company [link removed] a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:

$62,700.00

Pay Range Maximum:

$97,200.00

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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Originally posted on Himalayas