Ensure compliance with WellSky's Utilization Management and Compliance Program
Serve as a clinical expert on state and federal regulations
Analyze and present data to establish best practices across post-acute health care settings
Facilitate activities related to performance measurement and outcomes
Ensure the organization meets CMS, NCQA, and other regulatory standards
Stay updated on relevant regulatory changes
Support integration of regulatory changes into practices
Comply with state, federal, and organizational standards
Assist in development and enforcement of policies aligned with Utilization Management and Compliance requirements
Complete and successfully submit CMS reports
Conduct Root Cause Analysis (RCA) with Operational teams
Conduct regular compliance audits based on CMS UM standards
Develop and guide implementation of internal audit protocols
Generate and validate reports to monitor performance and compliance
Prepare for regulatory, accreditation, and contractual audits
Contribute to the remediation and documentation of audit findings
Perform other job duties as assigned.

At least 4-6 years relevant work experience
Advanced working knowledge of CMS UM audits
At minimum, 2-3 years of compliance experience focused on CMS and health plan audits
At minimum, 1-2 years of implementing CMS final rule changes and managing change management of processes
Bachelor's Degree or equivalent work experience
Active, unrestricted license: RN, PT, OT or SLP, with a bachelor’s degree in a related field or a combination of education and experience that includes pertinent clinical experience and advanced working knowledge of CMS standards and guidelines
Experience with NCQA audits
Must be able to prioritize, plan and handle multiple tasks and demands simultaneously, with competing deadlines
Excellent in manipulating and sorting data for analytics and reporting
Prior experience owning client compliance SLAs and ensuring success in meeting SLA requirements.

Clinical Compliance Program Manager

Key skills