11/23
JOB DESCRIPTION
JOB TITLE: UM Compliance Specialist FLSA STATUS: Non-Exempt
DEPARTMENT: Utilization Management
REPORTS TO: UM Manager
JOB SUMMARY:
The UM Compliance Specialist supports the Utilization Management (UM) Program, delegated reporting deliverables, and regulatory requirements for Imperial Health Plan / Imperial Health Holdings Medical Group (IHP/IHHMG). This position assists with NCQA Accreditation preparation and ongoing FDR compliance oversight, ensuring UM operations meet CMS, NCQA, DHCS, DHMC Knox-Keene requirements, and Health Plan standards.
ESSENTIAL JOB FUNCTIONS:
1. Delegation & Regulatory Compliance
- Serve as the UM Compliance Specialist liaison with Delegated Health Plan partners for ongoing UM reporting deliverables.
- Support monitoring of delegated UM activities for compliance with CMS, NCQA, DHCS, and Health Plan requirements.
- Assist with development and maintenance of UM policies, procedures, UM Program Description, and UM Work Plan.
- Track and maintain required UM reporting calendars, deliverables, and data sources.
2. Audit Support
- Assist in the organization, coordination, and submission of documents for UM audits (Health Plan, CMS, DHCS, NCQA, internal audits).
- Manage and maintain the UM audit repository and master audit dashboard.
- Track audit findings, CAP responses, and follow-up activities through resolution.
3. NCQA Accreditation Support
Assist the with planning and implementing NCQA Accreditation activities, including:
- Mock Survey preparation and readiness checks.
- Managing NCQA Survey repositories and maintaining NCQA document standards (annotation, bookmarking, version control).
- Managing the IRT web-based survey tool, uploading documents, and generating required reports.
- Developing stakeholder agendas, training materials, and distributing communications related to NCQA readiness.
- Creating best-practice toolkits, training, and reference resources for internal teams.
4. Training & Education
- Oversee Annual UM Training for UM staff and physician reviewers, including roster maintenance and documentation tracking.
- Support development of training materials for UM processes, audit readiness, accreditation requirements, and regulatory updates.
- Partner with internal teams to coordinate training sessions, track attendance, and monitor completion status.
5. Administrative & Project Support
- Schedule UM meetings, regulatory audit meetings, and project-related sessions.
- Prepare agendas, take meeting minutes, and track status updates for UM initiatives and projects.
- Assist in preparation of presentations/reports for Medical Services, QI Sub-Committees, UM governance, and NCQA workgroups.
6. Stakeholder & Member Support
- Act as a resource to staff, providers, and/or members for UM program information and compliance-related inquiries.
- Support communication flow between UM, Compliance, CM, Population Health, and external partners.
7. Compliance, Attendance & Conduct
- Adhere to payroll/timekeeping policies with minimal manual edits.
- Maintain regular and reliable attendance.
- Follow all IHHMG policies, including Compliance Plan, HIPAA regulations, and Standards of Conduct.
MARGINAL JOB FUNCTIONS:
- Perform special projects as assigned.
- Other duties as needed to support UM and Compliance operations.
BEHAVIORAL EXPECTATIONS:
Continuous Learning
- Attend department meetings, trainings, workshops, and seminars as required.
Customer Focus
- Maintain confidentiality and privacy in alignment with HIPAA and IHHMG Standards of Conduct.
- Foster professional communication with supervisors, coworkers, providers, and members.
Quality / Process Improvement
- Report safety, security, or compliance concerns promptly.
- Demonstrate adherence to policies, procedures, and regulatory standards.
POSITION REQUIREMENTS
Education / Experience
- High school diploma or equivalent required.
- Bachelor’s Degree or equivalent combination of education.
- Preferred: 2–3 years of experience in managed care, utilization management, quality, compliance, or accreditation for a Medicare Advantage and/or Medi-Cal plan or delegated medical group
Skills / Knowledge / Abilities
- Strong planning, organizational, and time-management skills.
- Ability to manage multiple tasks and changing priorities.
- Excellent communication skills (written, verbal).
- Ability to maintain confidentiality and professional conduct.
- Skilled in judgment, decision-making, and problem-solving.
- Ability to understand and comply with Federal, State, and local regulations.
- Proficiency with computer systems and tracking tools (e.g., audit repositories, survey tools, UM systems).
Licensure / Certification
