Clinical Quality and Regulatory Specialist

PacificSource; Georgia; Hybrid; USD 71,000 - 106,000; Full time

Job summary

PacificSource in Georgia is seeking an experienced Health Services Compliance Auditor to monitor and report on operations, audits, and delegated functions. You will ensure adherence to federal/state rules, assist with education programs, and collaborate across Compliance, leadership, and external auditors.

Minimum six years in nursing or behavioral health, with relevant licensure and knowledge of HIPAA, CMS/OMBP requirements.

Qualifications

• Six years nursing or clinical behavioral health experience required.
• Current, unrestricted state license(s) in nursing or behavioral health.
• Familiarity with health services regulations, audits, and contractual terms.

Responsibilities

• Collaborate with leadership to develop and conduct internal audits.
• Monitor operations for compliance with federal, state, and internal rules.
• Oversee vendor delegation and ensure service performance compliance.
• Monthly monitoring of staff and vendors involved in utilization management.
• Coordinate with FWA teams to identify and report issues.
• Provide interpretation and training on new regulatory requirements.
• Prepare reporting to federal/state agencies and internal committees.
• Participate in internal/external meetings and audits as needed.
• Apply LEAN and quality improvement to monitor KPIs and drive improvements.
• Assist with creating/update of compliant policies and onboarding materials.

Skills

Audit skills

Regulatory knowledge

Communication

Collaboration

Problem solving

Documentation

Education

Nursing license and/or behavioral health licensure

Tools

EHR systems

Compliance software

Job description

Looking for a way to make an impact and help people? Join PacificSource and help our members access quality, affordable care! PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths. Support all aspects of Health Services (Appeals and Grievances, Case Management, Utilization Management, and Medical Pharmacy) compliance by assuming a primary role in monitoring and reporting on Health Services operational activities and delegated functions. Collaborate with Health Services leadership and Compliance to oversee regulatory and delegated functions pertaining to Health Services. Maintain working knowledge of applicable Federal, State, industry, and organizational rules, regulations, standards, and contract language; conduct and participate in internal and external audits; and identify, investigate, and follow up on potential issues or opportunities for improvement. Assist in the creation and maintenance of compliant policies and procedures, member and provider letters and materials, and employee resources. In conjunction with the leadership and training teams, assist with the development of employee education/orientation programs that will encompass onboarding new employees as well as continuing education for all Health Services staff as applies to regulations.

Essential Responsibilities

• Collaborate with Health Services leadership and Compliance to develop and conduct internal audits to assess and ensure compliance with Federal, State, organizational, and industry rules, regulations, and standards.
• Perform routine and ad hoc monitoring activities of Health Services operations to ensure compliance with applicable rules, regulations, and standards; report findings to Health Services leadership, Compliance, and appropriate internal committees as necessary.
• Perform delegation oversight activities of applicable vendors to ensure delegated functions are complying with applicable rules and regulations and meeting service agreement performance standards, report findings to Health Services leadership and applicable internal committees.
• Conduct at least monthly monitoring of staff, including vendors and sub-contractors, who are involved in utilization management decision-making to ensure consistency with application of clinical policies (i.e., care guidelines, clinical criteria) and compliance with required processing timeframes.
• Serve as liaison between Health Services, Compliance, and Fraud, Waste, and Abuse (FWA) teams with identifying, reporting, and, as assigned, investigating FWA cases.
• Maintain a current working knowledge of State contract language and all applicable Federal, State, organizational, and industry rules, regulations, standards, and best-practices; provide assessment, interpretation, impact reporting, and training on new and revised rules, regulations, and requirements.
• Collaborate with Health Services leadership, regulatory and reporting staff, and Compliance to respond to all compliance-related inquiries from internal and external auditors in a timely, professional, and accurate manner to ensure minimal organizational and operational impact.
• Oversee, prepare, present, submit required reporting to Federal, State, and industry agencies (e.g., quarterly utilization management (UM) reports to Oregon Health Authority (OHA)) and organizational committees (e.g., trending and data reports to Clinical Quality and Utilization Management (CQUM) committee).
• Attend and actively participate as presenter or Health Services representative in internal and external meetings, committees, and audits as assigned.
• Utilize LEAN methodologies and quality improvement principles to practice and promote continuous improvement; utilize visual boards and daily huddles to monitor and communicate key performance indicators (KPI) and identify opportunities for improvement and evaluation of actions taken.
• Participate in routine monitoring of internal documents and materials, including but not limited to policies and procedures, desk top references, training materials, member and provider letters and handbooks, and create or revise accordingly and in collaboration with other internal communities to ensure compliance with applicable rules, regulations, and standards and alignment with organizational branding.
• Contribute to and support the implementation and maintenance of an employee education program that encompasses new and existing employee, vendor and subcontractor onboarding, that addresses operational and regulatory requirements and updates, and pertains to practices relevant to Health Services.

Supporting Responsibilities

• Act as backup for other Health Services department staff as needed and within scope of licensure.
• Serve on designated committees, teams, and task groups, as directed.
• Represent the Heath Services department, both internally and externally, as requested by Medical Director and Health Services leadership.
• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

SUCCESS PROFILE

Work Experience: A minimum of six years nursing or clinical behavioral health experience with varied health care exposure and experience required. A minimum 2 years insurance industry experience required. Demonstrated knowledge and experience with program development and auditing preferred.

Education, Certificates, Licenses: Registered Nurse; Licensed Clinical Psychologist, Licensed Clinical Social Worker, or comparable behavioral health professional with extensive experience and/or credentials (e.g., Licensed Professional Counselor, Licensed Marriage and Family Therapist, Psychiatric Mental Health Nurse Practitioner). Current unrestricted state license(s). Within 2 years in this position, obtain Certified Case Manager (CCM) as accredited by CCMC (The Commission for Case Management Certification) preferred, or 60 CEUs in Utilization Management areas of focus.

Knowledge: Thorough knowledge and understanding of medical procedures, diagnoses, care modalities, procedure codes including ICD-10, DSM-IV, and CPT Codes, health insurance and State-mandated benefits. Thorough knowledge and understanding of options available within and without contractual benefits. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Proficient in the use and implementation of the following tools and concepts across all teams within scope of accountability: strategy deployment, daily operations, visual management, operational improvement, auditing. Establishes and maintains relationships with internal and external customers. Maintains current clinical knowledge base and certification. Ability to work independently with minimal supervision and collaboratively in a team as indicated.

Competencies: Adaptability Building Customer Loyalty Building Strategic Work Relationships Building Trust Continuous Improvement Contributing to Team Success Planning and Organizing Work

Environment

• Work inside in a general office setting with ergonomically configured equipment.
• Travel is required approximately 10% of the time.

Skills

• Accountability
• Collaboration
• Communication (written/verbal)
• Flexibility
• Listening (active)
• Organizational skills/Planning and Organization
• Problem Solving
• Teamwork

Compensation Disclaimer

The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range.

Base Range: $70,950.00 - $106,424.99

Our Values

• We are committed to doing the right thing.
• We are one team working toward a common goal.
• We are each responsible for customer service.
• We practice open communication at all levels of the company to foster individual, team and company growth.
• We actively participate in efforts to improve our many communities-internally and externally.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements

• Stoop and bend.
• Sit and/or stand for extended periods of time while performing core job functions.
• Repetitive motions to include typing, sorting and filing.
• Light lifting and carrying of files and business materials.
• Ability to read and comprehend both written and spoken English.
• Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.