Overview
Quality Assurance Compliance Specialist Jobs in United States at My Health
Title: Quality Assurance Compliance Specialist
Company: My Health
Location: United States
My Health is excited to announce a new Quality/Compliance RN position within our clinical operations team!
The Quality/Compliance RN is responsible for ensuring that My Health’s Utilization Review (UR) and Case Management (CM) processes adhere to regulatory, accreditation, and quality standards. This role plays a critical part in maintaining compliance with state and federal healthcare regulations, supporting accreditation efforts, and improving the quality of services provided to members.
Key Responsibilities:
Compliance & Regulatory Oversight
Ensure MyHealth’s UR and CM activities comply with state and federal regulations (CMS, URAC, NCQA, HIPAA, ERISA, etc.).
Conduct internal audits of UR/CM processes to identify gaps and implement corrective actions.
Monitor changes in healthcare regulations and provide recommendations for policy updates.
Assist with the preparation and submission of accreditation documentation.
Support external audits and regulatory reviews by providing documentation and compliance reports.
Quality Assurance & Improvement
Develop and implement quality improvement initiatives for UR/CM operations.
Analyze trends in utilization management, case management outcomes, and member complaints to identify opportunities for enhancement.
Work with data analysts to track key performance indicators (KPIs), such as cost savings, reduced unnecessary utilization, and member satisfaction.
Provide training and education to UR/CM staff on compliance, documentation standards, and regulatory updates.
Clinical Review & Documentation
Review UM and CM case files to ensure adherence to evidence-based guidelines (e.g., MCG criteria, state-mandated clinical protocols).
Ensure appropriate clinical decision-making processes are followed for preauthorization and concurrent reviews.
Support the Appeals & Grievances team in reviewing cases for medical necessity and compliance with MyHealth policies.
Assist in standardizing documentation practices to improve efficiency and regulatory adherence.
Any other job duties assigned
Required Qualifications:
Education: Bachelor’s Degree in Nursing (BSN) required; Master’s Degree in Healthcare Administration or related field preferred.
Licensure: Active RN license in residing state.
Experience: Minimum of 5 years of experience in Utilization Review, Case Management, or Quality Compliance.
Certifications (Preferred but Not Required):
Certified Case Manager (CCM)
Certified Professional in Healthcare Quality (CPHQ)
Certified in Healthcare Compliance (CHC)
URAC/NCQA Accreditation Experience
Skills & Competencies:
Strong knowledge of URAC, NCQA, CMS, HIPAA, and state-specific regulations.
Experience with utilization management software (e.g., MCG, Milliman, InterQual).
Excellent analytical and auditing skills for reviewing compliance and quality metrics.
Ability to train and educate staff on compliance-related matters.
Strong problem-solving and decision-making skills.
Effective communication skills to collaborate with internal teams and external regulatory agencies.
Work Environment & Schedule:
Remote
Full-time, Monday through Friday schedule with potential flexibility based on audit and compliance needs.
Occasional travel may be required for accreditation, audits, or training purposes.
Why Join My Health?
Be part of a forward-thinking organization that is transforming utilization and case management with concierge-level services.
Work in an innovative environment that values compliance, quality, and patient-centered care.
Opportunity to play a key role in achieving regulatory excellence and operational efficiency.
My Health is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.
