Clinical Quality and Regulatory Specialist

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 problems.

Responsibilities

Assures department compliance with regulatory guidelines/agencies including NCQA, CMS, DPW, and DOH; Supports integration of new vendors and lines of business; Manages oversight, development and maintenance of case management policies and procedures; Monitors regulatory changes, industry trends, and contract changes; Manages and coordinates department activities including policy/procedure development, audits, and operations compliance; Conducts audits, monitors and reports noncompliance; Develops and implements corrective action plans; Researches federal and state regulations; Reviews and provides input into policies and procedures for regulatory requirements; Performs internal clinical and non-clinical audits for quality assurance; Creates and implements corporate tools and processes; Communicates effectively with internal and external customers; Coordinates and facilitates workgroups; Supports integration of new lines of business; Monitors delegated entities and prepares reports; Serves as 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 experience evaluating, implementing or revising work processes; Experience in workforce development and resource management with excellent team building and professional development skills; Must demonstrate excellent leadership skills and be able to relate to all levels of management and staff as well as individuals external to the corporation; Experience in staff/project management; Strong leadership, collaboration, and motivational skills; Ability to multi task and perform in a fast paced, and often intense environment; Excellent written and verbal communication skills; Ability to analyze data, measure outcomes and develop action plans; Be enthusiastic, innovative and flexible; Team player that possesses strong analytical and organizational skill; The ability to prioritize work demands and meet deadlines; Excellent computer and software knowledge and skills

Nice to have

Bachelor’s degree; 3 or more years’ experience in performing auditing/monitoring functions; 3 or more years’ experience creating tools, training documents and educational materials geared to adult learners; 3 years’ experience with Microsoft Office products; 3 or more years’ experience working in the health care/health insurance industry; Quality Management System certification