Clinical Quality and Regulatory Specialist (Healthcare)

TL;DR

Clinical Quality and Regulatory Specialist (Healthcare): Ensuring departmental compliance with regulatory guidelines and accreditation standards for case management processes with an accent on audit execution, policy development, and risk identification. Focus on integrating new lines of business, monitoring regulatory changes, and collaborating across corporate departments to maintain high-quality standards.

Location: Must be based in Pennsylvania

Company

hirify.global is a national health and wellness organization and one of the largest integrated health care delivery and financing systems in the United States.

What you will do

• Manage and coordinate department activities including policy development, staff audits, and operational compliance.
• Conduct internal clinical and non-clinical audits to ensure adherence to regulatory requirements and corporate policies.
• Monitor delegated entities, identify risks, and develop corrective action plans to minimize organizational impact.
• Research federal and state regulations, Medicaid bulletins, and CMS coverage determinations to ensure ongoing compliance.
• Collaborate with internal and external stakeholders to resolve issues and communicate process changes effectively.
• Prepare reports and provide performance metrics to management and regulatory agencies.

Requirements

• Current clinical license (LCSW, LSW, LPC, or RN) required.
• 3-5 years of experience in case management or managed care.
• 2 years of experience with quality measurement systems.
• 1 year of experience evaluating or revising work processes.
• Must be based in Pennsylvania.
• Strong analytical, organizational, and leadership skills with the ability to work in a fast-paced environment.

Nice to have

• Bachelor’s degree.
• 3+ years of experience in auditing or monitoring functions.
• 3+ years of experience creating training materials for adult learners.
• Quality Management System certification.

Culture & Benefits

• Commitment to diversity and inclusion with strong anti-discrimination policies.
• Opportunities for professional development and leadership growth.
• Collaborative environment working across various corporate departments.
• Focus on ethical business conduct and data security compliance.