Clinical Compliance Specialist - LVN - SWHR CIN - Remote

Support Services
21003436 Requisition #
244 Total Views

Southwestern Health Resources is seeking to hire a Clinical Compliance Specialist Licensed Vocational Nurse to support our Utilization Management Department.


The address: Work from home (Remote). Must live within the Dallas-Fort Worth Area.


Salary range is $24.14/hour – Max 37.97/hour – based on relevant experience.


Work Schedule  

• Full-time: 40 hours per week, Days, 8am-5pm, Rotating weekend call.


The Clinical Compliance Specialist RN will assist the compliance supervisor with coordinating and performing all pre-delegation and annual due diligence audits and monitoring of delegated activities to ensure compliance with NCQA, URAC,

contractual agreements, and State and Federal requirements. The compliance specialist will assist with internal monitoring and preparation of compliance reports to present to management. The essential job duties for this position are:


 Monitoring of compliance programs, policies, and procedures designed to ensure compliance with all applicable federal laws and Medicare Advantage (MA) regulations.

•  Preparing audit files for submission as required.

•  Performing tasks related to external audits from contracted health plans as well as pre-delegation review with potential health plans as required.

•  Coordinating with delegated partners to ensure adherence to all regulations, contractual agreements, CMS, NCQA, and

•  Maintenance of compliance activity documents, such as logs, complaints received, audits, and audit outcomes.

•  Following up on corrective action plans ensuring timely closure.

•  Supplying information in delegation audits.

•  Demonstrates proficiency in the application of health plan coverage guidelines, CMS coverage guidelines, and nationally recognized review criteria.

•  Demonstrates the ability to develop departmental interfaces with internal and external customers to provide exemplary service and achieve goals.

•  Provides assistance to internal and external auditors during compliance reviews.

•  Achieves ongoing compliance with regulatory agencies.

•  Reviews and adheres to department policies and the Utilization Management Plan

•  Perform other duties as assigned.

The ideal candidate will possess the following qualifications:

•  High School Diploma or Equivalent required And.

•  Nursing graduate of accredited vocational nursing school required.

•  3 Years of experience in Medicare Advantage or Managed Care required And.

•  3 Years of experience in Utilization Review, Discharge Planning and Medical Case Management in hospital or post-acute care setting preferred Or

•  2 Years of case management experience in an acute or post-acute provider or health plan or other care company experience preferred

•  Knowledge of Medicare and health plan criteria, and Acuity UM Application preferred.

•  LVN - Licensed Vocational Nurse required.



•  Working knowledge of computers and basic software application used in job functions such as word processing, graphics, databases, spreadsheets, etc.


Southwestern Health Resources Clinically Integrated Network (SWHR CIN) is a partner company of Texas Health. If hired for this position, you will become a SWHR CIN employee rather than a Texas Health employee.


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