Assures the highest standards of clinical quality and regulatory compliance across Utilization Management department activities for all government lines of business and delegated vendors.
Confirms Utilization Management’s compliance with federal, state, and regulatory guidelines (e.g., NCQA, CMS).
Assists with policies and procedures, and continually monitoring regulatory changes.
Collects, analyzes, and interprets clinical data, clinical outcomes, and performance metrics to prepare comprehensive reports and audit responses.
Collaborates across departments to resolve issues and provide education on regulatory requirements and best practices.

Minimum Current license in one or more of the following disciplines: LCSW, LSW, LPC, or other related clinical license (OR) Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).
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.

Clinical Quality and Regulatory Specialist

About this role