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Corporate Functions & Operations WellCare - Clinical Compliance Careers

Health Services Clinical Quality Specialist Job

Full Job Title: HS Clinical Quality Spec, Sr

Job Number: 1703112

Location: Tampa, FL

Date Posted: 7-13-2017

Performs clinical file audits and guides staff members completing clinical file audits for evidence of compliance with state, contractual and regulatory requirements regarding Care Management (case/disease management and utilization management). Mentors and trains staff members less experienced in the auditing process for clinical compliance. Leads efforts to develop clinical audit tools to appropriately capture evidence of compliance with contractual and regulatory standards. Presents audit results and actively participates in department initiatives and projects.

Department: HS-Case Management

Reports to: Mgr. Clinical Ops Oversight

Location: Tampa, FL.


Essential Functions:

  • Conducts file audits as assigned for Care Management clinical adherence which includes utilization management, case management and disease management.
  • Participates in the development and ongoing review of audit tool clinical elements that accurately capture adherence with required standards. Develops process flows with focus on regulatory requirements, documentation of departmental processes, report generation, and process improvement.
  • Reviews Care Management program descriptions, policies and procedures, step actions, and training materials as well as State Contracts when needed to evaluate alignment of audit elements, departmental processes, staff training, and contractual/regulatory standards.
  • Utilizes clinical knowledge and experience to evaluate documentation of member health assessments, clinical needs and interventions in meeting compliance standards.
  • Reviews policies and procedures, provides updates and collaborates with policy and procedure team to ensure compliance with state and federal regulations. Researches legal/regulatory documentation and performs analysis, including the review and summarization of regulatory requirements, updates, and/or changes.
  • Participates in meetings with Care Management and others to discuss audit findings, areas of opportunity and recommendations for improvement.
  • Appropriately escalates areas of concern identified during clinical file audits.
  • Participates as needed with preparation for State and Regulatory audits by collecting and /or reviewing evidence.
  • Meets established productivity and accuracy standards for file reviews.
  • Follows departmental audit guidelines and processes.
  • Other duties and special projects as assigned.
Additional Responsibilities:Candidate Education:
  • Required A Bachelor's Degree in a related field
Candidate Experience:
  • Required 4 years of experience in clinical environment (inpatient or outpatient)
  • Required 1 year of experience in Managed care (UM, BH, CM, DM)
  • Required Other Familiarity with Medicare and Medicaid programs
  • Preferred Other Previous State or Federal care compliance experience
Candidate Skills:
  • Intermediate Ability to effectively present information and respond to questions from peers and management
  • Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
  • Advanced Demonstrated time management and priority setting skills
  • Intermediate Demonstrated interpersonal/verbal communication skills
  • Intermediate Ability to work as part of a team
  • Intermediate Other Ability to read and interpret state and federal laws and regulations in relation to organization clinical documentation
  • Intermediate Other Ability to assess clinical documentation in relation to audit standards and make recommendations for improvement based on findings
Licenses and Certifications:
A license in one of the following is required:
  • Required Other A license in on of the following is required:
  • Licensed Registered Nurse (RN)
  • Licensed Practical Nurse (LPN)
  • Licensed Clinical Social Worker (LCSW)
  • Licensed Mental Health Counselor (LMHC)
  • Licensed Clinical Marriage & Family Therapist (LCMFT)
Technical Skills:
  • Required Intermediate Microsoft Excel Strong knowledge of Microsoft Office (including Outlook, Word, Excel, Powerpoint, and Access)
  • Required Intermediate Microsoft Word
  • Required Intermediate Microsoft Outlook
  • Required Beginner Microsoft PowerPoint Knowledge of flow charting tool to create and maintain process flows
  • Preferred Beginner SharePoint
  • Preferred Beginner Microsoft Visio

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Last Updated On: 12/9/2015