Clinical Quality and Regulatory Specialist

PacificSource Health Plans

. Support compliance across Health Services, including Appeals and Grievances, Case Management, Utilization Management, and Medical Pharmacy .

Posted 11/11/2026full-timeRemote • Florida • United StatesMid-LevelSenior💰 $70,950 - $106,425 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates extensive knowledge of compliance in Health Services, including Appeals and Grievances, Case Management, and Utilization Management. Proficient in conducting audits, monitoring operations, and ensuring adherence to regulatory requirements while effectively communicating with stakeholders.

Highest-signal resume keywords

Registered NurseCertified Case Manager (CCM)Utilization ManagementICD-10HIPAA Compliance

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Behavioral Health ExperienceInsurance Industry ExperienceMedical Procedures KnowledgeOperational ImprovementAuditingData Recording and RetrievalPolicy RevisionLEAN MethodologiesQuality Improvement PrinciplesKPI Monitoring

Soft Skills

Effective CommunicationTeam CollaborationIndependent WorkTraining and Education

Certifications & Qualifications

Current Unrestricted State LicenseCertified Case Manager (CCM)

Industry Keywords

Health ServicesComplianceFraud, Waste, and AbusePatient ConfidentialityState-Mandated Benefits

About the role

Key responsibilities & impact

Support compliance across Health Services, including Appeals and Grievances, Case Management, Utilization Management, and Medical Pharmacy
Monitor and report on Health Services operational activities and delegated functions
Collaborate with Health Services leadership and Compliance on regulatory and delegated functions
Develop and conduct internal audits for compliance with Federal, State, organizational, and industry requirements
Perform routine and ad hoc monitoring of Health Services operations and report findings
Conduct delegation oversight of vendors and subcontractors
Monitor staff and vendors involved in utilization management decision-making at least monthly
Serve as liaison between Health Services, Compliance, and Fraud, Waste, and Abuse teams
Maintain knowledge of applicable rules, regulations, standards, best practices, and State contract language
Assess, interpret, report impacts, and train employees on new and revised requirements
Respond to compliance inquiries from internal and external auditors
Prepare, present, and submit required reports to agencies and organizational committees
Participate in meetings, committees, and audits as a presenter or Health Services representative
Apply LEAN methodologies and quality improvement principles, using visual boards and daily huddles to monitor KPIs
Monitor and revise policies, procedures, training materials, letters, handbooks, and other documents for compliance and branding
Support employee, vendor, and subcontractor education and onboarding programs
Act as backup for other Health Services staff within scope of licensure
Serve on designated committees, teams, and task groups
Represent Health Services internally and externally as requested
Follow privacy and HIPAA requirements and perform other assigned duties

Requirements

What you’ll need

Minimum of six years nursing or clinical behavioral health experience with varied health care exposure
Minimum of two years insurance industry experience
Registered Nurse; Licensed Clinical Psychologist; Licensed Clinical Social Worker; or comparable behavioral health professional with extensive experience and/or credentials
Current unrestricted state license(s)
Within 2 years in this position, obtain Certified Case Manager (CCM) as accredited by CCMC, preferred, or 60 CEUs in Utilization Management areas of focus
Thorough knowledge of medical procedures, diagnoses, care modalities, ICD-10, DSM-IV, and CPT Codes
Knowledge of health insurance and State-mandated benefits
Ability to use computerized systems for data recording and retrieval
Knowledge of patient confidentiality, privacy, and health records security
Proficiency in strategy deployment, daily operations, visual management, operational improvement, and auditing
Ability to work independently with minimal supervision and collaboratively in a team
Ability to read and comprehend written and spoken English
Ability to communicate clearly and effectively
Must meet department and company performance and attendance expectations
Must follow PacificSource privacy policy and HIPAA laws and regulations

Benefits

Comp & perks

Full-time employment
Work from home designation (WFH: FL)
Professional development through employee education, orientation, and continuing education programs
Opportunity to obtain Certified Case Manager (CCM) certification or complete 60 CEUs in Utilization Management areas of focus
Ergonomically configured equipment
Equal opportunity employment and diversity-focused workplace
Travel approximately 10% of the time