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Clinical Quality & Regulatory Specialist - GHP

Highmark Wholecare

  • Company April 2022 Ed (1)
  • Pittsburgh, PA
  • Clinical Services
  • Full time
  • Day (United States of America)

Company :

Highmark Wholecare

Job Description : 


This job ensures that all 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 oversight, development and maintenance of case management policies and procedures related to ensure accreditation and compliance with CMS and DPW requirements. Works closely with other departments within 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 basis.  Educates staff and management as needed, both formal and informal. Suggests new approaches to complex problems.


  • Manage 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.
  • Develop and implement modifications needed to workload plan to ensure completion.
  • Provide service support, training and performance metrics/statistics to the team in addition to initiating and implementing process improvements.
  • Identify and escalate issues appropriately.
  • Apply clinical knowledge to the development of policies/processes.
  • Conduct audits, monitor and report all noncompliance to the appropriate management, audit or corporate compliance personnel, and responds to corporate compliance requests and requirements. 
  • Contribute to the development of corrective action plans.  Implement those plans in conjunction with the management staff.
  • Research federal and state regulations and other regulatory materials (ex:  Medicaid bulletins, CMS Coverage Determinations, etc.), various business requirement contracts, and subcontracted delegated entity.
  • Gather information and prepare reports in response to inquiries from regulatory agencies and/or internal customers.
  • Review and provide input into the oversight of policies and procedures to support regulatory requirements related to Case Management.
  • Develop and implement appropriate audit requirements in order to ensure compliance with all staff activity related to Case Management. 
  •  Perform 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.)
  • Create and implement common corporate tools and processes to effectively monitor individual staff and overall department compliance, including but not limited to:  conducting complex audits for appropriate application of policies/procedures, business approaches and federal and state regulations and statutes as well as accreditation standards.
  • Recommend and develop corrective action plans to management. 
  • Oversee final plan implementation and communication.
  • Display effective communication skills.
  • Maintain consistent and open lines of communication with internal and external customers.
  • Communicate changes in processes and programs order to enhance a share vision and mission.
  • Effectively communicate outcomes, data analysis, complex processes and action plans to division/unit staff, corporate partners, and external customers.
  • Facilitate and lead informational and educational meetings for internal and external customers as assigned.
  • Demonstrate excellent interpersonal, verbal and written skills.
  • Collaborates across departments.
  • Accountable for special projects and enhanced activities within the department.
  • Participate in the development and implementation of department/division projects.
  • Involved in the implementation of integration processes and planning activities.
  • Coordinate and/or facilitate workgroups.
  • Support integration of new lines of business as assigned.
  • Monitor delegated entity on a routine basis and obtains or prepare periodic reports, as needed, for management, the Delegation Oversight Committee, and/or regulatory agency.
  • Identify risks and develop plans to minimize impact to the organization, and share findings.
  • Identify issues pertaining to delegate and develop recommendations to correct, which may include a formal corrective action plan.
  • Provide delegate with clear expectations of requirements as a result of various regulations, contracts, and corporate initiatives.
  • Serve as department point person for specific delegated entities as assigned.
  • Other duties as assigned or requested.



  • Current license in one or more of the following disciplines: RN, LCSW, LSW, LPC, or other related clinical license
  • 3-5 years’ experience in case management/managed care with specific knowledge of quality monitoring, compliance and/or regulatory processes
  • 2 years of experience with quality measurement systems
  • 1 year of experience evaluating, implementing or revising work processes


  • None


  • Bachelor’s degree
  • 3 years of experience in performing auditing/monitoring functions
  • 3 years of experience creating tools, training documents and educational materials geared to adult learners
  • 3 years of experience with Microsoft Office products
  • 3 or years of experience working in the health care/health insurance industry
  • Quality Management System certification


  • Experience in workforce development and resource management with excellent team building and professional development skills
  • Must demonstrate excellent leadership skills and be able to relate to all levels of management and staff as well as individuals external to the corporation
  • Experience in staff/project management
  • Strong leadership, collaboration, l and motivational skills
  • Ability to multi task 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
  • Team player that possesses strong analytical and organizational skill
  • The ability to prioritize work demands and meet deadlines
  • Excellent computer and software knowledge and skills


Does this role supervise/manage other employees?



Is Travel Required?


Disclaimer: 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 position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

Highmark 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 their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. 

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