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 operational activities, and ensuring adherence to regulatory standards and best practices.

Highest-signal resume keywords

Registered NurseCertified Case Manager (CCM)Utilization ManagementCompliance MonitoringHealth Insurance Knowledge

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

ICD-10DSM-IVCPT CodesOperational ImprovementAuditingLEAN MethodologiesData RecordingPolicy DevelopmentTraining Material CreationKPI Monitoring

Soft Skills

Effective CommunicationTeam CollaborationIndependent WorkProblem SolvingPresentation Skills

Tools & Technologies

Computerized SystemsVisual BoardsDaily Huddles

Certifications & Qualifications

Current Unrestricted State LicenseCertified Case Manager (CCM)

Industry Keywords

Health ServicesComplianceFraud, Waste, and AbusePatient ConfidentialityHIPAA RequirementsState-Mandated BenefitsContractual BenefitsBehavioral HealthClinical KnowledgeHealth Records Security

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
Perform routine and ad hoc compliance monitoring and report findings
Perform delegation oversight of vendors and subcontractors
Monitor staff involved in utilization management decision-making at least monthly
Serve as liaison with Compliance and Fraud, Waste, and Abuse teams
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 and 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
Use visual boards and daily huddles to monitor KPIs and identify improvement opportunities
Monitor, create, and revise policies, procedures, training materials, letters, handbooks, and other internal documents
Support employee, vendor, and subcontractor education and onboarding programs
Provide backup for other Health Services staff within scope of licensure
Serve on designated committees, teams, and task groups
Represent Health Services internally and externally
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)
Certified Case Manager (CCM) within 2 years, 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
Knowledge of contractual benefits and options available within and outside those 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
Current clinical knowledge base and certification
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
Ability to meet performance and attendance expectations
Ability to follow PacificSource privacy policy and HIPAA laws and regulations
Travel approximately 10% of the time

Benefits

Comp & perks

Certified Case Manager (CCM) certification within 2 years, preferred, or 60 CEUs in Utilization Management areas of focus
Employee education, onboarding, and continuing education programs
Equal opportunity employment
Continuous improvement and professional development opportunities
General office setting with ergonomically configured equipment