RN Quality / Compliance

CommuniCare Health; Blue Ash (OH); Remote; USD 70,000 - 90,000; Full time

Job summary

MyHealth, part of the CommuniCare family, invites applications for a Quality/Compliance RN role to ensure adherence to healthcare regulations and enhance service quality. Join a mission-driven team dedicated to patient-centered care and operational excellence in an innovative healthcare environment.

Benefits

Flexible working schedule

Opportunity for professional development

Comprehensive benefits package

Qualifications

• Active RN license in residing state.
• Minimum of 5 years in Utilization Review, Case Management, or Quality Compliance.
• Certifications like CCM or CPHQ preferred.

Responsibilities

• Ensure compliance with state and federal regulations.
• Conduct internal audits of processes.
• Develop quality improvement initiatives for operations.

Skills

Compliance knowledge

Analytical skills

Auditing skills

Training skills

Problem-solving

Communication

Education

Bachelor’s Degree in Nursing (BSN)

Master’s Degree in Healthcare Administration (preferred)

Tools

Utilization management software

Job description

Job Address:

10123 Alliance Road, Suite 320Blue Ash, OH 45242

Quality / Compliance RN

MyHealth is excited to announce a new Quality/Compliance RN position within our clinical operations team.

About Us

MyHealth, part of the CommuniCare family of companies, is focused on helping members make informed decisions about their healthcare. We simplify the process by doing the heavy lifting—navigating insurance, coordinating care, and providing personalized support every step of the way. We’re a growing, mission-driven team that values collaboration, compassion, and innovation.

Position Overview

The Quality/Compliance RN is responsible for ensuring that MyHealth’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 Case Manager (CCM)
  • Certified Professional in Healthcare Quality (CPHQ)
  • Certified in Healthcare Compliance (CHC)
  • URAC/NCQA Accreditation Experience

Skills & Competencies

• 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.

Work Environment & Schedule

• 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 MyHealth?

• 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.

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

#LI-Remote

About Us

Since 1984, CommuniCare Family of Companies has been committed to delivering exceptional person-centered care as a national leader in post-acute care for those that are chronically ill or have complex conditions. Our more than 150 skilled nursing, assisted living, and long-term care facilities deliver sophisticated and transformative care to nearly 16,000 residents and patients at any given time. CommuniCare employs more than 19,000 employees across six states (Ohio, Indiana, Maryland, Virginia, West Virginia and Pennsylvania).

As a family owned and operated company, family and heart are woven into every aspect of our continuum of care. Our mission, to serve with pride, is evident and a quality residents, families and community partners have come to expect and trust. Dedicated to improving the lives of seniors, we put extraordinary service above all else. We continue to raise the bar and innovate wherever possible to deliver a higher quality of life for those far beyond our facilities. Because of this, our facilities are a better place for residents to live, patients to stay, employees to work and families to heal.