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Role Description

The Clinical Compliance & Quality Specialist is responsible for ensuring regulatory and quality compliance across clinical operations. This role requires consistent use of independent judgment and discretion in evaluating, auditing, and improving clinical systems and processes. The specialist collaborates with internal teams and external regulatory bodies to uphold standards set by state, federal, and accreditation organizations.

Responsibilities

• Ensure compliance with state, federal, and accreditation standards, including ERISA, NCQA, URAC, and HIPAA.
• Conduct internal and external audits of clinical programs, prepare detailed reports, participate in case file preparation and mark-up for audits.
• Monitor clinical trial activities to ensure protocol adherence and regulatory alignment.
• Identify and manage risks related to clinical quality and compliance, review and approve Standard Operating Procedures (SOPs), and collaborate with cross-functional teams to resolve quality issues and implement improvements.
• Train clinical staff on regulatory requirements, quality standards, and department objectives.
• Develop and maintain evidence-based training materials and software tools, and deliver training in various modalities (classroom, virtual, self-learning, and one-on-one) to adult learners with different levels of experience.
• Track and report training activities and employee progress, updating department leadership on staff who are not meeting expectations.
• Participate in quality audit programs and conduct monthly sample quality analysis audits to identify gaps and training opportunities.
• Support corrective action plans as directed by management and provide comprehensive follow-up.
• Maintain current knowledge of industry regulations, accreditation standards, and evidence-based practices to support staff education.
• Maintain professionalism and cohesiveness within the team as a representative of the training department and attend all mandatory department and training meetings.
• Demonstrate proficiency in Microsoft Office Suite and Smartsheet.
• Perform other related duties as assigned to meet departmental and company objectives.
• Possess 3 years of experience leading, mentoring, and training staff, with a strong ability to teach diverse audiences and adapt methods to varying learning needs.
• Completed advanced coursework in teaching and/or mentoring, continually seeking innovative approaches to deliver best-in-class managed care education.

Qualifications

• In-depth knowledge of state and federal regulations, including HIPAA, CMS, NCQA, and URAC.
• Ability to interpret and apply evidence-based guidelines and accreditation standards to clinical operations.
• Skilled in conducting internal and external audits of clinical programs.
• Proficient in case file preparation, SOP review, and audit mark-up.
• Capable of producing detailed audit reports and recommending corrective actions.
• Excellent analytical thinking and problem-solving abilities.
• Able to identify compliance risks and propose mitigation strategies.
• Uses written resources independently to resolve issues.
• Exceptional attention to detail in reviewing clinical documentation and audit trails.
• Maintains accurate records and ensures data integrity.
• Excellent verbal and written communication skills for both upward and downward communication.
• Ability to speak clearly and explain complex or technical information in an understandable way.
• Experienced in training clinical staff and developing training materials.
• Basic computer literacy and after training (3 months total), must be able to work in various software and systems.
• Ability to work on multiple screens and proficient typing skills.
• Manages multiple audits or projects simultaneously.
• Works well independently and meets deadlines with minimal supervision.
• Maintains strict confidentiality and adheres to ethical standards in handling PHI and sensitive data.
• Demonstrates professional integrity in all compliance-related activities.
• Familiarity with medical claims and ICD-10, CPT, HCPCS coding.
• Understands clinical workflows and documentation standards.

Requirements

• Holds an active unrestricted Registered Nursing License Required.
• May require additional licensure.
• Bachelor’s Degree preferred.
• 3-5 years UR, CM, DM experience required.
• Managed care experience preferred.
• CPHQ and/or CCM certification preferred.

Benefits

• Competitive base salary and benefits effective day one.
• Comprehensive medical and dental through our own health solutions.
• Unlimited PTO—rest and recharge time is non-negotiable.
• Mental health support, retirement planning, and financial protection.
• Professional development with clear career progression and learning budgets.
• Mission-driven culture where diverse perspectives drive real impact on people's health.