Clinical Quality and Regulatory Specialist

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.

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 Standards

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

Base Range

$70,950.00 - $106,424.99

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.