Clinical Compliance Program Manager
New
United StatesFull-TimeManager
Salary not disclosed
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Job Details
- Experience
- 4–6 years
- Required Skills
- Data AnalysisChange Management
Requirements
- 4–6 years of relevant experience in healthcare compliance, utilization management, or clinical operations
- Strong knowledge of CMS utilization management audits and regulatory requirements (minimum 2–3 years required)
- Experience implementing CMS rule changes and supporting related change management processes
- Bachelor’s degree or equivalent combination of education and clinical experience
- Active, unrestricted clinical license (RN, PT, OT, or SLP preferred)
- Familiarity with NCQA audit processes and healthcare accreditation standards
- Strong analytical skills with the ability to manipulate, interpret, and report complex healthcare data
- Experience managing compliance SLAs and supporting client or organizational audit readiness
- Ability to manage multiple priorities and deadlines in a fast-paced environment
- Strong communication, organizational, and collaboration skills
Responsibilities
- Support the organization’s Utilization Management and Compliance Program by ensuring alignment with CMS, NCQA, and other regulatory standards
- Conduct compliance audits, including reviews of expedited, standard, and other case types in accordance with CMS UM requirements
- Perform root cause analysis with operational and clinical teams to identify issues and recommend corrective actions
- Develop, implement, and maintain internal audit protocols aligned with regulatory and accreditation standards
- Generate, validate, and analyze compliance and performance reports across health plan contracts
- Support the preparation for regulatory, accreditation, and contractual audits
- Assist in developing and enforcing clinical and operational policies
- Monitor regulatory changes and support their integration into internal processes
- Contribute to the consistency and accuracy of clinical documentation and decision-making
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