Clinical Quality and Regulatory Specialist

PacificSource; Springfield (OR); On-site; USD 80,000 - 100,000; Full time

Job summary

PacificSource is seeking a Health Services Compliance professional to support all aspects of compliance, including monitoring, reporting, and audits. The role collaborates with leadership to oversee regulatory and contracted functions and to address potential issues and opportunities for improvement.

The position emphasizes LEAN-based process improvement, adherence to HIPAA regulations, and collaboration with Compliance to respond to inquiries from auditors and internal committees.

Qualifications

• Minimum six years in health services compliance or related field.

Responsibilities

• Collaborate with Health Services leadership and Compliance to develop and conduct internal audits.
• Monitor and report on regulatory and delegated functions pertaining to Health Services.
• Prepare and present required reporting to Federal, State, and industry agencies and internal committees.

Skills

Regulatory compliance

HIPAA compliance

LEAN methodologies

Audit coordination

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