Clinical Quality and Regulatory Specialist

Company

reputed company.Job Description :

GENERAL OVERVIEW:

Assures that reputed company department activities are compliant with regulatory guidelines/agencies, including but not limited to: NCQA, CMS, DPW, and DOH. Supports the integration of new vendors and lines of business, including processes, procedures, risk identification, education, and delegation follow up. Manages the reputed company, development and maintenance of case management policies and procedures reputed company to ensure accreditation and compliance with CMS and DPW requirements. Works closely with other departments reputed company the corporation to resolve issues and ensure activities coincide with Case Management processes. Provides consultation to the department. Monitors regulatory changes, industry trends, and contract changes on an ongoing reputed company. Educates staff and management as needed, both formal and informal. Suggests new approaches to reputed company problems.

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 action 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. Quality

• 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 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 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 well as accreditation standards.
• Recommends and develops corrective action 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.
• Seek 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 action 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 projects and enhanced activities reputed company the department.

• Participation in the development and implementation of department/division projects.
• 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 impact to the organization, and reputed company findings.
• Identifies issues pertaining to delegate and reputed company recommendations to correct, which may include a formal corrective action plan.
• Provides delegate with re