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 • Georgia • 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 standards while effectively communicating with stakeholders.

Highest-signal resume keywords

Registered NurseCertified Case Manager (CCM)Utilization ManagementICD-10, DSM-IV, CPT CodesHealth Insurance Knowledge

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Behavioral Health ExperienceInternal AuditsData Recording and RetrievalOperational ImprovementPolicy Monitoring and Revision

Soft Skills

Effective CommunicationTeam CollaborationIndependent Work

Tools & Technologies

Computerized SystemsLEAN MethodologiesVisual Management

Certifications & Qualifications

Current Unrestricted State LicenseCertified Case Manager (CCM)

Industry Keywords

Health Services ComplianceFraud, Waste, and AbusePatient ConfidentialityState-Mandated BenefitsHealth Records Security

About the role

Key responsibilities & impact

Support compliance across Health Services, including Appeals and Grievances, Case Management, Utilization Management, and Medical Pharmacy
Collaborate with Health Services leadership and Compliance on regulatory and delegated functions
Develop and conduct internal audits
Perform routine and ad hoc monitoring of Health Services operations
Perform delegation oversight of vendors and subcontractors
Monitor utilization-management decision-making staff at least monthly for clinical-policy consistency and processing-timeframe compliance
Liaise with Health Services, Compliance, and Fraud, Waste, and Abuse teams to identify, report, and investigate cases
Maintain knowledge of Federal, State, organizational, and industry rules, regulations, standards, best practices, and State contract language
Assess, interpret, and report impacts of new and revised requirements; provide training
Respond to compliance-related inquiries from internal and external auditors
Prepare, present, and submit required reports to agencies and organizational committees
Participate in internal and external meetings, committees, and audits as a presenter or Health Services representative
Apply LEAN methodologies and quality-improvement principles, visual boards, and daily huddles to monitor KPIs and identify improvements
Monitor and revise policies, procedures, references, training materials, member and provider letters, and handbooks
Support employee, vendor, and subcontractor education and onboarding programs
Provide backup support, serve on committees and task groups, and represent Health Services as requested
Follow privacy policy and HIPAA requirements; perform other duties as assigned

Requirements

What you’ll need

A minimum of six years nursing or clinical behavioral health experience with varied health care exposure and experience required
A minimum 2 years insurance industry experience required
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, or 60 CEUs in Utilization Management areas of focus
Thorough knowledge and understanding of medical procedures, diagnoses, care modalities, ICD-10, DSM-IV, and CPT Codes
Knowledge of health insurance and State-mandated benefits and contractual 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
Approximately 10% travel required

Benefits

Comp & perks

Within 2 years in this position, obtain Certified Case Manager (CCM) as accredited by CCMC, or 60 CEUs in Utilization Management areas of focus
Employee education, onboarding, and continuing education programs
Equal opportunity employment and commitment to diversity, equity, and inclusion
General office setting with ergonomically configured equipment