Compliance Nurse

Job Title: RN Care Management Coordinator – Compliance Specialist (Remote, Tri-State Area)

Location: Remote (Candidates must reside in the Tri-State Area)

License Requirement: PA Licensed Registered Nurse (RN) only — No LPN candidates

The Compliance Specialist plays a critical role in ensuring that Utilization Management (UM) operations comply with all relevant regulations and standards, including NCQA, CMS, and various state requirements. This role involves monitoring the medical review process to confirm appropriate medical necessity determinations, accurate application of Inter Qual criteria and medical policies, and proper documentation for referral and letter generation. The Compliance Specialist also coordinates business operations related to NCQA activities such as surveys and document maintenance, along with supporting various projects and initiatives.

• Evaluate and interpret regulations and standards (NCQA, CMS, and state-specific), ensuring appropriate controls are implemented and maintained. Recommend and oversee the adoption of new controls as needed.
• Conduct monthly compliance audits and report findings, trends, and potential issues affecting operational efficiency and quality to management and directors.
• Perform ongoing sample case reviews to verify correct application of Inter Qual criteria, medical policies, and appropriate referrals to Medical Directors. Ensure that submitted information is accurate and facilitates informed decision-making.
• Ensure clinical staff documentation within the medical management system is thorough, accurate, and meets regulatory standards for clear and understandable member communications.
• Serve as a resource for both internal teams and external stakeholders, providing professional, timely, and effective communication.
• Support NCQA-related business operations, including survey preparation and annual documentation updates.
• Perform additional duties as assigned.

• Minimum of five (5) years of clinical experience.
• Active Pennsylvania Registered Nurse (RN) license required. BSN preferred.
• Strong interpersonal skills with the ability to provide constructive feedback while fostering positive, collaborative working relationships.
• Solid knowledge of utilization review processes and management systems, with moderate to strong expertise in Inter Qual.
• Exceptional verbal and written communication skills, with meticulous attention to detail.
• Proficiency in Microsoft Excel, PowerPoint, and Word.
• Demonstrated experience with NCQA, CMS, and other regulatory compliance programs.
• Strong problem-solving, organizational, and planning skills.

• Mid-Senior level

• Contract

• Health Care Provider and Analyst

• Hospitals and Health Care