Clinical Quality and Regulatory Specialist (Healthcare)

Location: Remote, work at home in Pennsylvania, United States. Travel is required.

Company

hirify.global provides health insurance and healthcare services subject to clinical, regulatory, privacy, and compliance requirements.

What you will do

• Manage regulatory activities, including policy and procedure development, staff audits, compliance monitoring, reporting, and corrective action plans.
• Oversee quality audits related to Case Management, including operational, quality improvement, and accreditation mock audits.
• Research federal and state regulations, Medicaid bulletins, CMS coverage determinations, contracts, and delegated-entity requirements.
• Monitor delegated entities, identify risks and compliance issues, and coordinate recommendations and remediation plans.
• Prepare reports, analyze outcomes and performance metrics, and communicate complex findings to internal and external stakeholders.
• Support projects, workgroups, new lines of business, staff training, and process improvement initiatives.

Requirements

• Must work remotely from Pennsylvania, United States.
• Current LCSW, LSW, LPC, another related clinical license, current state RN license, or current multistate eNLC licensure.
• 3–5 years of experience in case management or managed care, including quality monitoring, compliance, or regulatory processes.
• At least 2 years of experience with quality measurement systems and 1 year evaluating, implementing, or revising work processes.
• Strong analytical, organizational, leadership, communication, collaboration, and project management skills.
• Knowledge of healthcare regulations, audits, compliance processes, data analysis, and Microsoft Office products.

Nice to have

• Bachelor’s degree.
• Three or more years of auditing or monitoring experience.
• Experience creating tools, training documents, and educational materials for adult learners.
• Quality Management System certification.
• Experience in healthcare or health insurance, workforce development, resource management, or staff and project management.

Culture & Benefits

• Remote work arrangement with required travel.
• Cross-department collaboration with internal and external customers.
• Work involving healthcare compliance, confidential customer information, HIPAA, and data security requirements.
• Opportunities to support staff education, professional development, and process improvement.