Job Description

Summary/Objective:

The Medical Management Regulatory Manager ensures compliance with federal, state, and local regulations related to medical management operations, including utilization management, case management, and quality improvement. This role involves monitoring regulatory updates, implementing compliant processes, and coordinating audits to maintain adherence to healthcare standards.

Essential Functions:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Ensure Regulatory Compliance

• Monitor and interpret changing healthcare regulations, including Medicare,
• Medicaid, HIPAA, state-specific guidelines, NCQA, Commercial products.
• Develop policies to ensure the organization complies with regulatory requirements, avoiding penalties and legal issues.

Streamline Medical Management Processes

• Optimize processes related to utilization management, care coordination, and claims review.
• Align medical management practices with industry standards and legal requirements.

Risk Mitigation

• Identify potential risks related to non-compliance and develop mitigation strategies.
• Ensure adherence to accreditation standards from organizations such as NCQA.

Support Organizational Strategy

• Provide expert advice on integrating regulations into strategic planning for healthcare delivery.
• Assist in developing training programs for staff to understand regulatory requirements.

Cost Control and Efficiency

• Reduce unnecessary healthcare expenditures by ensuring accurate utilization reviews and approvals.
• Enhance operational efficiency by standardizing regulatory workflows.
• Support and deliver regulatory reporting and performance initiatives.

Expertise in a Complex Environment

• Healthcare regulations are complex and constantly evolving; a specialist ensures the organization stays informed and adaptable.
• Provide leadership in audits and reviews by regulatory bodies.

Improve Member Outcomes and Satisfaction

• Develop policies that prioritize quality care while meeting regulatory requirements.
• Ensure compliance with member rights regulations to enhance trust and satisfaction.

Education:

• Bachelor’s degree in bachelor’s in nursing (BSN) healthcare administration, nursing, public health, or a related field preferred
• Minimum 3–5 years of experience in medical management, compliance, or regulatory affairs in a healthcare setting.
• Active Nursing licensure in the commonwealth of Pennsylvania preferred

Skills/Abilities :

• Proficient in Microsoft Office (Microsoft Word, Microsoft Excel, Microsoft PowerPoint, Microsoft Access and Visio).
• Excellent organizational, written and oral communication skills.
• Excellent interpersonal skills.
• Ability to prioritize work, meet deadlines and work independently.
• Ability to interact with staff as a team player.
• Able to deal with sensitive data in a highly confidential manner.
• In-depth knowledge of healthcare regulations and standards (e.g., HIPAA, CMS, NCQA).
• Strong analytical and problem-solving skills.
• Excellent attention to detail.
• Ability to communicate complex regulatory information clearly.
• Certified Professional in Healthcare Quality (CPHQ), Certified Compliance Professional (CCP), or similar credential preferred.

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