Clinical Quality and Regulatory Specialist

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: RN, LCSW, LSW, LPC, or other related clinical license
• 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 excellent team building and professional development skills
• Must demonstrate excellent leadership skills and be able to relate to all levels of management and staff as well as individuals external to the corporation.
• Experience in staff/project management
• Strong leadership, collaboration, l and motivational skills
• Ability to multi task and perform in a fast paced, and often intense environment
• Excellent written and verbal communication skills
• Ability to analyze data, measure outcomes and develop action plans
• Be enthusiastic, innovative and flexible.
• Team player that possesses strong analytical and organizational skill
• The ability to prioritize work demands and meet deadlines
• Excellent computer and software knowledge and skills

IV. SCOPE OF RESPONSIBILITY 

Does this role supervise/manage other employees?

No

V. WORK ENVIRONMENT

Is Travel Required?

Yes

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

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