Clinical Quality and Regulatory

Clinical Quality and Regulatory Specialist

Highmark Health all cities,AK

Description:

Regulatory Compliance Manager

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:

• 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 elevate 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.
• 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.
• Communication:
  Effectively communicate - 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…