Case Management Compliance & Quality Leader

Highmark; United States; On-site; USD 90,000 - 130,000; Full time

Job summary

Highmark Inc. is seeking a Regulatory Compliance professional to assure case management activities meet NCQA, CMS, DPW and DOH standards. You will steward policy development, audits, and staff training while coordinating with teams to implement corrective actions.

The role requires strong leadership, regulatory knowledge, and the ability to drive improvement in a fast-paced healthcare environment.

Qualifications

• Current clinical license in LCSW/LSW/LPC or related field.
• Active RN license or multi-state licensure via eNLC.
• 3–5 years in case management/managed care with quality/regulatory focus.
• 2 years with quality measurement systems; 1 year evaluating/revising processes.
• Preferred: Bachelor’s degree and auditing/monitoring experience.

Responsibilities

• Advance regulatory compliance for case management and policy development.
• Conduct audits, monitor noncompliance, and prepare regulatory reports.
• Develop corrective action plans and ensure timely implementation.
• Educate staff, coordinate across departments, and lead meetings.
• Oversee delegated entities and manage risk mitigation activities.
• Lead process improvements and project-based initiatives.

Skills

Regulatory compliance

Quality monitoring

Communication

Project management

Delegation oversight

Leadership

Data analysis

Auditing

Education

Clinical license (LCSW/LSW/LPC or equivalent)

RN license or multi-state licensure (eNLC)

Microsoft Office proficient

Tools

Microsoft Office

Job description

Highmark Inc. is seeking a Regulatory Compliance professional to assure case management activities meet NCQA, CMS, DPW and DOH standards. You will steward policy development, audits, and staff training while coordinating with teams to implement corrective actions.

The role requires strong leadership, regulatory knowledge, and the ability to drive improvement in a fast-paced healthcare environment.