Clinical Quality and Regulatory Specialist

Company :

Highmark Inc.

Job Description :

Assures the highest standards of clinical quality and regulatory compliance across Utilization Management department activities for all government lines of business and delegated vendors, playing a critical role in maintaining accreditation and evolving regulatory landscapes. The individual in this role will confirm Utilization Management’s compliance with federal, state, and regulatory guidelines (e.g., NCQA, CMS), assisting with policies and procedures, and continually monitoring regulatory changes.

The specialist is the key individual responsible for collecting, analyzing, and interpreting clinical data, clinical outcomes, and performance metrics to prepare comprehensive reports and audit responses, including UM program descriptions and evaluations. Additionally, this role involves working closely with utilization management leadership and other departments to resolve issues and provide education on regulatory requirements and best practices.

• 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 escalates 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.

• 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.

• 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.

• Participation in the development and implementation of department/division projects.
• Involvement in the implementation of integration processes and planning activities.
• Coordinates and/or facilitates work groups.
• Supports integration of new lines of business as assigned.

• 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.