The Compliance Specialist ensures staff compliance with Utilization Management regulations, including NCQA, CMS, and state requirements. Responsibilities include monitoring medical reviews, overseeing Inter. Qual application, and coordinating business support for NCQA activities. This role involves reporting trends, conducting case reviews, and serving as a resource. Location: 100% Remote WFH (Candidates will be remote but need to reside in the tri-state area) Pay Rate: $35-37 / Hourly (paid wee... more details
GHR healthcare is ready to help you Unlock Your Career: Join Us as a Utilization Management Specialist in Healthcare Excellence!
Job Summary:
The Compliance Specialist ensures staff compliance with Utilization Management regulations, including NCQA, CMS, and state requirements. Responsibilities include monitoring medical reviews, overseeing InterQual application, and coordinating business support for NCQA activities. This role involves reporting trends, conducting case reviews, and serving as a resource.
Location: 100% Remote WFH (Candidates will be remote but need to reside in the tri-state area)
Pay Rate: $35-37 /Hourly (paid weekly and eligible for benefits)
Hours: Monday – Friday (Normal business hours)
Responsibilities:
Assess and implement controls for NCQA, CMS, and State regulations.
Report monthly findings on efficiency and quality trends.
Conduct ongoing case reviews and ensure accurate documentation.
Serve as a resource for internal and external parties.
Other duties as assigned.
Qualifications:
Minimum 5 years clinical experience.
Active PA Licensed RN; BSN preferred.
Strong interpersonal skills and ability to provide feedback.
Knowledge of utilization review processes and InterQual.
Excellent communication skills.
Proficient in Excel, PowerPoint, and Word.
Experience with NCQA, CMS, and regulatory compliance.
Strong problem-solving and organizational skills.
Benefits and Perks
· Weekly direct deposit
· Health, dental, and vision insurance
· 401k with company matching
· W2 OR 1099
· Paid liability & workers’ comp coverage
· Flexible scheduling options
· Referral bonuses
· Personalized 1:1 career support before, during, & after assignments
About Us:
With over 30 years of healthcare staffing experience, GHR Healthcare is your trusted partner in finding the perfect locum tenens advanced practice role. Our specialized teams have placed thousands of ROLES [ex: Nurse Practitioners (NPs), Physician Assistants (PAs), in roles nationwide. You will have a dedicated career advisor, providing access to new opportunities and guidance every step of the way. Whatever your career goals are, GHR Healthcare is here to support you and find your perfect fit. Get to know us: www.ghrhealthcare.com
We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
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