Clinical Compliance Coordinator (Remote)

JOB SUMMARY This job is responsible for working with HHO clinical departments in the areas of compliance and process improvement. Serves as a corporate resource regarding accreditation standards, clinical performance and continuous improvement principles. Manages the oversight and development of clinical submissions for regulator inquiries. Oversees development and maintenance of Care Management policies and procedures to ensure accreditation and compliance with NCQA and DMMA requirements. Monitors regulatory changes, industry trends, and contract changes on an ongoing basis. Conducts analysis and oversight of design, development, modification, adaptation, implementation and execution of solutions for improvement of short‐term and long‐term clinical and operational excellence. Collaborates with various organizational leaders to prepare briefings or reports and conduct data analyses.COMPANY Highmark Inc.ESSENTIAL RESPONSIBILITIESServe as an internal project lead to ensure alignment and consistency in the organization's contractual clinical performance measurement across Care Management.Manage and coordinate department activities including but not limited to policy and procedure development and revision, individual staff audits, and overall operations to ensure compliance to standards and regulations. Serve as the point of contact and Highmark Health Options clinical representative to state regulators.Continuously examine processes and procedures to identify opportunities for improvement and refinement.Perform internal clinical audits for the purpose of quality assurance, and to assure compliance with respect to regulatory requirements and corporate policies/procedures.Recommend and develop corrective action plans to management. Oversee final plan implementation and communication.Effectively communicate outcomes, data analysis, complex processes and action plans to division/unit staff, corporate partners across departments and external customers.Research federal and state regulations and other regulatory materials, various business requirement contracts and subcontracted delegate entity to ensure compliance.Coordinate department accreditation, oversight and compliance activities with regulatory guidelines/agencies, including but not limited to NCQA and DMMA.Other duties as assigned or requested.REQUIRED EXPERIENCE5 years of experience working in a clinical setting.3 years of experience in case management/managed care (with specific knowledge of quality monitoring, compliance and/or regulatory processes).1 year of experience evaluating, implementing or revising work processes.PREFERRED EXPERIENCE3 years of experience performing auditing/monitoring functions.3 years of experience creating tools, training documents and educational materials geared to adult learners.3 years of experience in healthcare/health insurance industry.SKILLSWorkforce development and resource management with excellent team building and professional development skills.Strong leadership, collaboration, and motivational skills.Staff/project management.Ability to relate to all levels of management and staff as well as individuals external to the corporation.Ability to multitask and perform in a fast paced, and often intense environment.Excellent written and verbal communication skills.Ability to analyze data, measure outcomes and develop action plans.Be enthusiastic, innovative and flexible.Ability to prioritize work demands and meet deadlines.Excellent computer and software knowledge and skills.EDUCATION (Preferred)Bachelor's degree in business, health care administration, nursing, or other related program.REQUIRED LICENSES OR CERTIFICATIONSCurrent State of PA RN licensure OR Current multi‐state licensure through the enhanced Nurse Licensure Compact (eNLC), LCSW, LSW, LPC or related clinical licensure, within 45 days of hire.PREFERRED LICENSES OR CERTIFICATIONSNone.Language (Other Than English) NoneTravel Requirement 0% - 25%PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS Teaches / trains others Occasionally Travel from the office to various work sites or from site‐to‐site Rarely Works primarily out‐of‐the office selling products/services (sales employees) Never Physical work site required No Lifting up to 10 pounds Constantly Lifting 10 to 25 pounds Occasionally Lifting 25 to 50 pounds RarelyDisclaimer The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.Compliance Requirement This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.Pay Range Minimum: $67,500.00 Maximum: $126,000.00Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.We endeavor to make this site accessible to any and all 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@highmarkhealth.orgCalifornia Consumer Privacy Act Employees, Contractors, and Applicants Notice#J-18808-Ljbffr