Inland Empire Health Plans
Location
Rancho Cucamonga, CA | United States
Job description
Job Requisition ID: 10105
The Clinical Compliance Specialist, RN - Regulatory Oversight is responsible for the review of federal, state, and local regulations, contractual requirements, and accreditation standards to ensure IEHP policies comply in operation. Under the general direction of the Director of Regulatory Oversight, Health Services, this role will work closely with Health Services, Regulatory Affairs, and Compliance to ensure timely exchange of documentation to evidence compliance. The Clinical Compliance Specialist, RN - Regulatory Oversight is responsible for the development, implementation, and operation of the Clinical Compliance Program, including monitoring of Health Services departments (BH&CM, UM, Pharmacy, LTSS, CalAIM) to comply with DHCS, DMHC, and CMS regulations.
The Clinical Compliance Specialist, RN - Regulatory Oversight, will lead and provide expert technical assistance to highly visible, sensitive, and multifaceted projects. The incumbent will investigate compliance concerns identified, summarize findings, develop recommendations for corrective action plans, and provide oversight for the implementation of corrective action measures to promote and strengthen organizational compliance.
1. Implement and maintain all initiatives related to quality and regulatory requirements under the general direction of the Director, Regulatory Oversight, Health Services.
2. Oversee the continual maintenance of IEHP Policies/Procedures, letter templates, workflows, process, audit tools and training materials in compliance with regulatory requirements, new legislation, and accreditation standards.
3. Work collaboratively with Regulatory Affairs, PRO, Health Services and Compliance Audit and Oversight to ensure IEHP business units are made aware and department documents updated accordingly.
4. Prepare business units for review by external regulatory and accrediting bodies (Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), and Centers for Medicare and Medicaid Services (CMS), and internally for audits by Compliance.
5. Arrange and conduct mock audits within Health Services through e-mailing of pre-audit letters/audit tools and reporting requirements; supporting staff on coordination of scheduling mock audits, maintaining annual audit schedules, and submitting corrective action plans; ensuring follow-up with mailings of letters and CAPs are completed within timeframes; administering monitoring of all post-audit activities to ensure compliance with federal, state, and local requirements.
6. Participate in external audit support, with direction of Director of Regulatory Oversight, through collaboration with Health Services, PRO, Compliance and Provider Services, by monitoring and preparation of audit deliverables.
7. Conduct root cause analysis on red flag cases within Health Services.
8. Provide Health Services policy reviews in conjunction with Business Units and the PRO team.
9. Develop and implement programs utilizing Lean principles.
A minimum of three (3) years of experience in a Healthcare setting. A minimum of two (2) years of experience in a managed care setting. Must have experience in QA, audits, and regulations.
Associate’s degree from an accredited institution required.
Certification in Compliance (CHC), CCM, CPHQ is preferred.
Yes, must have a valid California Driver's License.
Knowledge of health plan regulations (DHCS, CMS, DMHC and NCQA). Knowledge of the Health Services Programs. Knowledge of Lean principles to problem solve and evaluate program effectiveness. Knowledge of quality assurance and performance improvement. Quality assurance knowledge. Care management and Care coordination knowledge.
Excellent verbal and written communication skills. Ability to use Microsoft products – Excel, Access, Power Point and Word. Skilled in public speaking. Policy reviews and editing skills. Excellent interpersonal skills. Ability to audit and summarize findings.
Ability to organize and follow through. Must be able to meet deadline.
The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.
Position may require travel and participation to external work groups/meetings.
A reasonable salary expectation is between $79,809.60 and $101,774.40, based upon experience and internal equity.
Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region, designated as “Great Place to Work.” With a provider network of more than 5,000 and a team of more than 3,000 employees, IEHP provides quality, accessible healthcare services to more than 1.5 million members. And our Mission, Vision, and Values help guide us in the development of innovative programs and the creation of an award-winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and make a difference with us! IEHP offers a competitive salary and stellar benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and state pension plan.
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