Clinical Compliance Specialist, RN

Date: Jun 21, 2022

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 7247 


Position Summary/Position


Under the general supervision of the VP/CCO, the Clinical Compliance Specialist is responsible for the review of federal, state, and local regulations, contractual requirements, and accreditation standards to ensure IEHP policies are in compliance and in operation. The position works closely with Regulatory Affairs, the SIU, and Compliance Audit and Oversight to ensure timely exchange of documentation to evidence compliance. The position is responsible for the internal auditing process for referral management and complex case management using approved auditing/monitoring tools. This position participates in the review and presentation, when necessary, of training materials for external delegates and internal staff training. The Clinical Compliance Specialist is responsible for the development, implementation, and operation of the Clinical Compliance Program, including monitoring of delegated activities to ensure compliance with federal, state, and local requirements.
The Clinical Compliance Specialist will lead and provide expert technical assistance to highly visible, sensitive, and multifaceted projects. S/he will investigate compliance concerns identified, summarize findings, develop recommendations for corrective action plans, and provide oversight for the implementation of corrective action measures to promote and strengthen organizational compliance.

Major Functions (Duties and Responsibilities)


1. Assists in the continual maintenance of IEHP Policies/Procedures, letter templates, workflows, process, audit tools and training materials in compliance with regulatory requirements, new legislation, and accreditation standards. Works collaboratively with Regulatory Affairs and Compliance Audit and Oversight to ensure IEHP business units are made aware and department documents updated accordingly.
2. Develops and maintains training materials in compliance with all regulatory requirements, new legislation, and accreditation standards.
3. Assists in the preparation of the business units for review by external regulatory and accrediting bodies (Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), and Centers for Medicare and Medicaid Services (CMS), and internally for audits by Compliance.
4. Assists in the development and revisions of audit tools, policies, and provider trainings to improve compliance with regulatory and accreditation standards.
5. Provides training, education, and consultation as necessary to delegates. Collaborates with UM and Delegation Oversight on identifying topics and developing agendas for the JOMs/performance visits/communications.
6. Leads coordination and performance of pre-delegation and annual audits for delegates. The Clinical Compliance Specialist is responsible for: arranging for mailing of pre-audit letters/audit tools and reporting requirements; supporting staff on coordination of scheduling audits, maintaining annual audit schedules, and submitting corrective action plans; ensuring follow-up with mailings of letters and CAPs are completed within timeframes; administering monitoring of all post-audit delegated activities to ensure compliance with federal, state, and local requirements.
7. Attends and presents at the Executive Compliance Committee, Quality Improvement Committee, and others, as appropriate. Directs and creates memos and applicable charts and graphs for committee presentation.
8. Stays informed about the latest developments in delegated oversight field, including new products and services, through relevant subject matter resources, professional associations, industry conferences, training seminars, and other information sources.
9. Maintains confidentiality in compliance with all Health Insurance Portability and Accountability Act (HIPAA) requirements.

Supervisory Responsibilities

Leading: Self

Experience Qualifications


Minimum of five (5) years of experience in a clinical setting and in a managed care plan performing UM oversight, including auditing. Managed Health Care experience. 

Education Qualifications


Associate’s degree in Nursing from an accredited institution required.

Preferred Education


Bachelor’s degree from an accredited institution preferred. 

Professional Certification


Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), Certified Professional in Healthcare Quality (CPHQ), Certified in Healthcare Compliance (CHC). 

Professional Licenses


Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required.

Drivers License Required

Yes, must have a valid California Driver's License.

Knowledge Requirement


Thorough knowledge and understanding of healthcare compliance and fraud, waste, and abuse principles and practices and Medicare and Medicaid regulations and guidelines. Good working knowledge of licensure and regulatory requirements, and accreditation standards. Knowledge of issues pertaining to Medi-Cal, Medicare, and other HMO & IPA contracts & payers.

Skills Requirement


Strong time management, problem solving, organizational and analytical skills. Excellent computer skills and proficiency in Microsoft Office applications as tested by IEHP. Effective interpersonal and communication skills, and excellent customer service. 

Abilities Requirement


Skilled at leading cross-functional work groups. Ability to maintain excellent interpersonal relationships within the department and at all levels of the organization. Ability to lead a team. Must be detail oriented. Excellent business judgment. Ability to manage multiple tasks and changing priorities.

Commitment to Team Culture


The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Work Model Location


Physical Requirements

Keyboarding: Traditional - FREQUENTLY
Keyboarding: 10-Key - FREQUENTLY
Keyboarding: Touch-Screen - FREQUENTLY
Hearing: One-on-One - FREQUENTLY
Communicate: Information/ideas verbally - FREQUENTLY
Near Visual Acuity - FREQUENTLY
Regular contacts: co-workers, supervisor - FREQUENTLY
Understand and follow direction - FREQUENTLY
Regular and reliable attendance - CONSTANTLY


Starting Salary: $79,809.60  - $101,774.40  

Pay rate will commensurate with experience


Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 7,000 and a team of more than 2,500 employees, IEHP provides quality, accessible healthcare services to more than 1.5 million members. And our Mission, Vision, and Values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and make a difference with us! IEHP offers a competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and state pension plan.


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles