Quality Assurance Compliance Specialist

My Health; United States; Remote; USD 60,000 - 85,000; Full time

Job summary

My Health is seeking a Quality/Compliance RN to join our clinical operations team. This full-time role involves ensuring adherence to healthcare regulations, conducting audits, and implementing quality improvement initiatives. Ideal candidates will have a BSN and significant experience in utilization review or case management. Join a forward-thinking organization that values compliance and quality care.

Benefits

Medical insurance

Vision insurance

401(k)

Qualifications

• Active RN license required.
• Minimum of 5 years in Utilization Review, Case Management, or Quality Compliance.
• Knowledge of CMS, URAC, NCQA, and HIPAA regulations.

Responsibilities

• Ensure compliance with state and federal regulations for UR and CM activities.
• Conduct internal audits and monitor regulatory changes.
• Develop quality improvement initiatives for UR/CM operations.

Skills

Analytical Skills

Auditing Skills

Problem-Solving Skills

Communication Skills

Education

Bachelor’s Degree in Nursing (BSN)

Master’s Degree in Healthcare Administration

Tools

Utilization Management Software

Job description

My Health is excited to announce a new Quality/Compliance RN position within our clinical operations team!

The Quality/Compliance RN is responsible for ensuring that My Health’s Utilization Review (UR) and Case Management (CM) processes adhere to regulatory, accreditation, and quality standards. This role plays a critical part in maintaining compliance with state and federal healthcare regulations, supporting accreditation efforts, and improving the quality of services provided to members.

Key Responsibilities:

Compliance & Regulatory Oversight

• Ensure MyHealth’s UR and CM activities comply with state and federal regulations (CMS, URAC, NCQA, HIPAA, ERISA, etc.).
• Conduct internal audits of UR/CM processes to identify gaps and implement corrective actions.
• Monitor changes in healthcare regulations and provide recommendations for policy updates.
• Assist with the preparation and submission of accreditation documentation.
• Support external audits and regulatory reviews by providing documentation and compliance reports.

Quality Assurance & Improvement

• Develop and implement quality improvement initiatives for UR/CM operations.
• Analyze trends in utilization management, case management outcomes, and member complaints to identify opportunities for enhancement.
• Work with data analysts to track key performance indicators (KPIs), such as cost savings, reduced unnecessary utilization, and member satisfaction.
• Provide training and education to UR/CM staff on compliance, documentation standards, and regulatory updates.

Clinical Review & Documentation

• Review UM and CM case files to ensure adherence to evidence-based guidelines (e.g., MCG criteria, state-mandated clinical protocols).
• Ensure appropriate clinical decision-making processes are followed for preauthorization and concurrent reviews.
• Support the Appeals & Grievances team in reviewing cases for medical necessity and compliance with MyHealth policies.
• Assist in standardizing documentation practices to improve efficiency and regulatory adherence.
• Any other job duties assigned

Required Qualifications:

• Education: Bachelor’s Degree in Nursing (BSN) required; Master’s Degree in Healthcare Administration or related field preferred.
• Licensure: Active RN license in residing state.
• Experience: Minimum of 5 years of experience in Utilization Review, Case Management, or Quality Compliance.

Certifications (Preferred but Not Required):

• Certified Professional in Healthcare Quality (CPHQ)
• Certified in Healthcare Compliance (CHC)
• URAC/NCQA Accreditation Experience
• Strong knowledge of URAC, NCQA, CMS, HIPAA, and state-specific regulations.
• Experience with utilization management software (e.g., MCG, Milliman, InterQual).
• Excellent analytical and auditing skills for reviewing compliance and quality metrics.
• Ability to train and educate staff on compliance-related matters.
• Strong problem-solving and decision-making skills.
• Effective communication skills to collaborate with internal teams and external regulatory agencies.
• Remote
• Full-time, Monday through Friday schedule with potential flexibility based on audit and compliance needs.
• Occasional travel may be required for accreditation, audits, or training purposes.

Why Join My Health?

• Be part of a forward-thinking organization that is transforming utilization and case management with concierge-level services.
• Work in an innovative environment that values compliance, quality, and patient-centered care.
• Opportunity to play a key role in achieving regulatory excellence and operational efficiency.

My Health is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.

Seniority level

• Seniority level

  Associate

Employment type

• Employment type

  Full-time

Job function

• Job function

  Quality Assurance

• Industries

  Insurance, Nursing Homes and Residential Care Facilities, and Hospitals and Health Care

Referrals increase your chances of interviewing at My Health by 2x

Inferred from the description for this job

Medical insurance

Vision insurance

401(k)

Get notified about new Quality Assurance Compliance Specialist jobs in United States.

QA Specialist III, QA Compliance (On-Site in College Station, TX)

QA Supervisor, QA Compliance (On-Site in College Station, TX)

United States $70,000.00-$85,000.00 1 week ago

Houston, TX $60,000.00-$75,000.00 1 week ago

Chicago, IL $60,000.00-$75,000.00 1 week ago

Winter Haven, FL $48,647.00-$77,710.00 4 days ago

Ohio, United States $60,000.00-$70,000.00 3 weeks ago

Associate Quality Control Analyst (Part Time)

North Carolina, United States 2 weeks ago

Thousand Oaks, CA $36.60-$38.90 1 week ago

Quality Assurance Specialist - HUB (Orlando, FL)

United States $70,400.00-$132,000.00 1 week ago

Quality Assurance Food Import Specialist

United States $65,000.00-$80,000.00 1 week ago

Program Specialist, Quality Control (Remote)

Quality Assurance Specialist (Remote in New York)

QC Investigator/CAPA Specialist (On-Site in College Station, TX)

Quality Assurance Specialist, Call Center

United States $37,000.00-$40,000.00 5 days ago

Santa Clara, CA $150,000.00-$170,000.00 5 days ago

Holly Springs, NC $36.00-$39.00 1 week ago

United States $70,000.00-$155,000.00 6 days ago

Supplier Quality Assurance Specialist - Quincy, IL or Remote

Quincy, IL $56,600.00-$105,600.00 1 day ago

We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.