• Specialist - Clinical Compliance Operations

    Job Locations Remote
    Job ID
    Clinical/Utililization Management
  • Overview

    The Specialist-Clinical Compliance position will coordinate with Director of Operational Compliance to establish an internal audit program based on compliance requirements, to identify areas of risk, and coordinate remediation of opportunities for improvement. Works with UM leadership to develop reporting, training and business support tools to ensure ongoing compliance with all requirements –both clinical and operational.


    • Prepare for and participate in customer delegation oversight audits relating to utilization management, including preparation of audit tools and audit files.
    • Serve as point of contact between operations and Corporate Compliance/Accreditation to receive updates on accreditation and regulatory requirements for UM and CareCentrix service delivery.
    • Establish, administer and monitor an internal audit program focused on compliance elements that incorporates expectations of external audits for accreditation and regulatory purposes.
    • Prepare for and participate in NCQA and URAC audits
    • Perform internal utilization review audits and identify opportunities for improvement.
    • Coordinate with Learning and Development to develop and deliver training to address improvement opportunities identified through audits
    • Coordinate with Reliability, BI, BT, CMI, etc to execute on system updates required as identified through audits
    • Monitor and communicate changes in accrediting standards and work with operational areas to implement changes required due to changes in accrediting standards
    • Assist with policy and desk level procedure updates and training as identified through audits
    • Work with UM Operations to promote accreditation and customer delegation oversight


    • Bachelor's Degree
    • Clear and active Registered Nurse/LPN/LVN (based on allowable state practice act) license in any state(s) or jurisdiction in the United States is required. Experience in training, written communication, and reports desired.
    • An experienced clinician with a minimum of 3 years of quality experience, preferably in the managed care setting is required.
    • Must have excellent interpersonal skills, ability to teach, thorough understanding of URAC, NCQA, CMS and state law standards pertaining to utilization management, project management skills, competent in the use of computers, statistical analysis, data display, auditing, skill with Microsoft Office.

    CareCentrix maintains a drug-free workplace in accordance with Florida's Drug Free Workplace Law.


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