Senior Clinical Services Compliance Specialist
Immediate need for a talented Senior Clinical Services Compliance Specialist . This is a full-time opportunity with long-term potential and is located in Philadelphia, PA ( Hybrid) . Please review the job description below and contact me ASAP if you are interested. Job Diva ID: 26-11544 Pay Range: $43- $46 /hour. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location). Key Responsibilities: Hybrid role - candidate will need to be onsite Turs, Wed, Thurs Collaborate with internal and external resources to develop program improvements, and to reengineer processes to assure service and compliance quality. Analysis of existing databases for relevant, reliable, and accurate data. Development of detailed illustrated specifications for reports, and develop detailed specifications for business intelligence and ad hoc audits and reports Research quality issues identified through regulatory agencies, Executive Inquiries, Consent Orders, Corporate Fraud Investigations, or other referral sources. Develop, refine, and update data tools for various audits, including tools for ad hoc audits. Analyzes audit findings and identifies credentialing process problems across business areas and recommends a plan of corrective action for resolution and follow up. Facilitate the Credentialing Program Description and Statement of Effectiveness and Program Descriptions for review and approval. Participate in developing and maintaining desk procedures and processing guides. Conduct gap analysis between requirements and corporate policies. Key Requirements and Technology Experience: Education Bachelor’s Degree, clinical license or relevant work experience. Minimum of five (5) years in a managed care setting. Detailed knowledge of NCQA accreditation, CMS state and federal laws and regulations. Excellent organizational, interpersonal, analytical, presentation and written skills required. Demonstrated ability to interact effectively with all levels of staff. Proven ability to work independently, prioritize workflow, maintain flexibility, and work as part of the departmental team Serves as a team facilitator and consultative resource for the organization. Demonstrated effective communication and analytical skills (emphasis on written skills) with the ability to work well with and associates of all levels through the family of companies. Experience analyzing data and coordinating projects. Strong writing skills for reporting Our client is a leading Health Insurance Industry , and we are currently interviewing to fill this and other similar fulltime positions. If you are interested in this position, please apply online for immediate consideration Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, colour, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws. By applying to our jobs, you agree to receive calls, AI-generated calls, text messages, or emails from Pyramid Consulting, Inc. and its affiliates, and contracted partners. Frequency varies for text messages. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. You can reply STOP to cancel and HELP for help. You can access our privacy policy here .
