Clinical Quality and Regulatory Specialist

About this role

Company : Highmark Inc. Job Description :  GENERAL OVERVIEW: Assures that all department activities are compliant with regulatory guidelines/agencies, including but not limited to: NCQA, CMS, DPW, and DOH. Supports the integration of new vendors and lines of business, including processes, procedures, risk identification, education, and delegation follow up. Manages the oversight, development and maintenance of case management policies and procedures related to ensure accreditation and compliance with CMS and DPW requirements. Works closely with other departments within the corporation to resolve issues and ensure activities coincide with Case Management processes. Provides consultation to the department. Monitors regulatory changes, industry trends, and contract changes on an ongoing basis. Educates staff and management as needed, both formal and informal. Suggests new approaches to complex problems.

ESSENTIAL RESPONSIBILITIES: 1. Regulatory Manages and coordinate department activities including but not limited to: policy and procedure development and revision, individual staff audits, overall operations to ensure compliance to standards and regulations. Develops and implement modifications needed to workload plan to ensure completion Provides service support, training and performance metrics/statistics to the team in addition to initiating and implementing process improvements. Identifies and escalate issues appropriately. Applies clinical knowledge to the development of policies/processes. Conducts audits, monitors and reports all noncompliance to the appropriate management, audit or corporate compliance personnel, and responds to corporate compliance requests and requirements. Contributes to the development of corrective action plans. Implements those plans in conjunction with the management staff. Researches federal and state regulations and other regulatory materials (ex: Medicaid bulletins, CMS Coverage Determinations, etc.), various business requirement contracts, and subcontracted delegated entity. Gathers information and prepares reports in response to inquiries from regulatory agencies and/or internal customers.

2. Quality Reviews and provides input into the oversight of policies and procedures to support regulatory requirements related to Case Management. Develops and implements appropriate audit requirements in order to ensure compliance with all staff activity related to Case Management. Performs internal clinical and non-clinical audits for the purpose of quality assurance, and to assure compliance with respect to regulatory requirements and corporate policies/procedures. (Ex: operational audits, quality improvement audits, accreditation mock audits, etc.) Creates and implements common corporate tools and processes to effectively monitor individual staff and overall department compliance, including but not limited to: conducting complex audits for appropriate application of policies/procedures, business approaches and federal and state regulations and statutes as well as accreditation standards. Recommends and develops corrective action plans to management. Oversees final plan implementation and communication.

3. Communicate effectively - this position displays effective communication skills while performing the following functions: Maintain consistent and open lines of communication with internal and external customers. Seek always to communicate changes in processes and programs order to enhance a share vision and mission. Effectively communicate outcomes, data analysis, complex processes and action plans to division/unit staff, corporate partners, and external customers. Facilitate and lead informational and educational meetings for internal and external customers as assigned. Demonstrate excellent interpersonal, verbal and written skills. Collaborates across departments.

4. Project Management – the position has accountability for special projects and enhanced activities within the department. Participation in the development and implementation of department/division projects. Involvement in the implementation of integration processes and planning activities. Coordinates and/or facilitates workgroups. Supports integration of new lines of business as assigned.

5. Delegation Oversight Monitors delegated entity on a routine basis and obtains or prepares periodic reports, as needed, for management, the Delegation Oversight Committee, and/or regulatory agency. Identifies risks and develops plans to minimize impact to the organization, and share findings. Identifies issues pertaining to delegate and develop recommendations to correct, which may include a formal corrective action plan. Provides delegate with clear expectations of requirements as a result of various regulations, contracts, and corporate initiatives. Serves as department point person for specific delegated entities as assigned.

6. Other duties as assigned or requested.

III. QUALIFICATIONS: Education, Licenses/Certifications, and Experience Minimum Current license in one or more of the following disciplines: LCSW, LSW, LPC, or other related clinical license (OR) Current State RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC). 3-5 years’ experience in case management/managed care with specific knowledge of quality monitoring, compliance and/or regulatory processes 2 years experience with quality measurement systems 1 year experience evaluating, implementing or revising work processes

Preferred Bachelor’s degree 3 or more years’ experience in performing auditing/monitoring functions 3 or more years’ experience creating tools, training documents and educational materials geared to adult learners 3 years’ experience with Microsoft Office products 3 or more years’ experience working in the health care/health insurance industry Quality Management System certification

Knowledge, Skills and Abilities Experience in workforce development and resource management with e

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