RNCompliance Specialist

Intepros is seeking a candidate for RN Compliance Specialist with one of our healthcare clients. Candidates will be remote, but need to reside in the tri-state area. PA/NJ License is required for this role. LPN's with compliance experience considered as well

Compliance Specialist Responsibilities:

Assesses regulations and standards (NCQA, CMS and State) and assures appropriate controls are in place, making recommendations and overseeing implementation of new controls where necessary

Performs ongoing sample case reviews to assure that staff are applying InterQual and medical and departmental policy guidelines correctly and referring appropriate cases to the Medical Director. Assures that information provided to the Medical Director is relevant and helpful in making determinations

Assures that clinical staff are documenting appropriately in medical management system so that member letters are clear, understandable, and meet regulatory requirements

Compliance Specialist Qualifications:

Active PA Licensed Registered Nurse required

Registered nurse, BSN Preferred

Knowledge of utilization review processes and utilization management systems, moderate to strong knowledge of InterQual required

Experience adhering to NCQA, CMS and other programs requiring regulatory compliance