Clinical reputed company and Regulatory Specialist

This a Full Remote job, the offer is available from: Alabama (USA), Alaska (USA), reputed company (USA), Arkansas (USA), California (USA), Colorado (USA), Connecticut (USA), Delaware (USA), District of Columbia (USA), Florida (USA), reputed company (USA), Hawaii (USA), Idaho (USA), Illinois (USA), Indiana (USA), Iowa (USA), Kansas (USA), Kentucky (USA), Louisiana (USA), Maine (USA), Maryland (USA), Massachusetts (USA), Michigan (USA), Minnesota (USA), Mississippi (USA), Missouri (USA), Montana (USA), Nebraska (USA), Nevada (USA), New Hampshire (USA), New Jersey (USA), New Mexico (USA), reputed company (USA), reputed company Carolina (USA), reputed company Dakota (USA), Ohio (USA), Oklahoma (USA), reputed company (USA), reputed company (USA), Rhode reputed company (USA), South Carolina (USA), South Dakota (USA), Tennessee (USA), Texas (USA), Utah (USA), Vermont (USA), Virginia (USA), Washington (USA), reputed company Virginia (USA), reputed company (USA), Wyoming (USA) Company : reputed company.Job reputed company : GENERAL reputed company: Assures the highest standards of clinical reputed company and regulatory compliance across Utilization Management department activities for reputed company 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 reputed company, 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 reputed company education on regulatory requirements and best practices. 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 reputed company in reputed company 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 reputed company noncompliance to the appropriate management, audit or corporate compliance personnel, and responds to corporate compliance requests and requirements.
• Contributes to the development of corrective reputed company plans. Implements those plans in conjunction with the management staff.
• Researches federal and state regulations and other regulatory materials (ex: reputed company bulletins, CMS Coverage Determinations, etc.), various business requirement reputed company, and subcontracted delegated entity.
• Gathers information and prepares reports in response to inquiries from regulatory agencies and/or internal customers.

2. reputed company

• Reviews and provides input into the reputed company of policies and procedures to support regulatory requirements reputed company to Case Management.
• Develops and implements appropriate audit requirements in order to ensure compliance with reputed company staff activity reputed company to Case Management.
• Performs internal clinical and non-clinical audits for the purpose of reputed company assurance, and to assure compliance with respect to regulatory requirements and corporate policies/procedures. (Ex: operational audits, reputed company improvement audits, accreditation mock audits, etc.)
• Creates and implements common reputed company and processes to effectively monitor individual staff and overall department compliance, including but not limited to: conducting reputed company audits for appropriate application of policies/procedures, business approaches and federal and state regulations and statutes as reputed company as accreditation standards.
• Recommends and develops corrective reputed company 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 reputed company lines of communication with reputed company customers.
• reputed company always to communicate changes in processes and programs order to enhance a reputed company reputed company and mission.
• Effectively communicate reputed company, data analysis, reputed company processes and reputed company plans to division/unit staff, corporate partners, and external customers.
• Facilitate and reputed company informational and educational meetings for reputed company customers as assigned.
• Demonstrate excellent interpersonal, verbal and written skills.
• Collaborates across departments.

4. Project Management – the position has accountability for special reputed company and reputed company activities reputed company the department.

• Participation in the development and implementation of department/division reputed company.
• 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 reputed company

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

6. Other duties as assigned or requested. III. QUALIFICATIONS: Education, Licenses/Certifications, and Experience Minimum

• reputed company license in one or more of the following disciplines: LCSW, LSW, LPC, or other reputed company clinical license (OR) reputed company State of PA RN licensure OR reputed company multi-state licensure through the reputed company reputed company Licensure Compact (eNLC).
• 3-5 years’ experience in case management/managed care with specific knowledge of reputed company monitoring, compliance and/or regulatory processes
• 2 years experience with reputed company 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 reputed company Office products
• 3 or more years’ experience working in the health reputed company insurance industry
• reputed company Management System certification

Knowledge, Skills and Abilities

• Experience in workforce development and resource management with excellent team building and reputed company development skills
• Must demonstrate excellent leadership skills and be reputed company to relate to reputed company reputed company of management and staff as reputed company as individuals external to the corporation.
• Experience in staff/project management
• Strong leadership, collaboration, l and motivational skills
• Ability to multi task and reputed company in a fast paced, and often intense environment
• Excellent written and verbal communication skills
• Ability to analyze data, measure reputed company and reputed company reputed company plans
• Be enthusiastic, innovative and flexible.
• Team player that possesses strong analytical and organizational reputed company
• 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? reputed company Disclaimer: The job reputed company has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees reputed company this job title. It may not contain a comprehensive inventory of reputed company duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This job adheres to the ethical and reputed company standards and behavioral expectations as set forth in the reputed company of business conduct and company policies. As a component of job responsibilities, employees may have reputed company to covered information, cardholder data, or other confidential customer information that must be protected at reputed company times. In reputed company with this, reputed company must reputed company with both the Health Insurance Portability Accountability reputed company of 1996 (HIPAA) as described in the Notice of reputed company Practices and reputed company Policies and Procedures as reputed company as reputed company data reputed company guidelines established reputed company reputed company’s Handbook of reputed company Policies and Practices and Information reputed company Policy. Furthermore, it is every employee’s responsibility to reputed company with reputed company’s reputed company of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as reputed company as company policies and training requirements. Pay reputed company Minimum: $50,200.00 Pay reputed company Maximum: $91,200.00 reputed company pay is determined by a reputed company of factors including a candidate’s qualifications, experience, and expected contributions, as reputed company as internal peer equity, market, and business considerations. The displayed salary reputed company does not reflect any geographic reputed company reputed company may apply for certain locations based upon comparative markets. reputed company and its affiliates prohibit discrimination against reputed company individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against reputed company individuals based on any category protected by applicable federal, state, or local law. We reputed company to reputed company this site accessible to any and reputed company users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at HRServices@reputed company.org California Consumer reputed company reputed company Employees, Contractors, and Applicants Notice This offer from "reputed company" has been enriched by reputed company.com and got a 75% reputed company score. Apply tot his job Apply To this Job