UM Regulatory Manager

Job Details

The Medical Management Regulatory Manager ensures compliance with federal, state, and local regulations related to medical management operations, including utilization management, case management, and quality improvement. This role involves monitoring regulatory updates, implementing compliant processes, and coordinating audits to maintain adherence to healthcare standards.

Job Description

Essential Functions:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Ensure Regulatory Compliance

• Monitor and interpret changing healthcare regulations, including Medicare,

Medicaid, HIPAA, state-specific guidelines, NCQA, Commercial products.

• Develop policies to ensure the organization complies with regulatory requirements, avoiding penalties and legal issues.

Streamline Medical Management Processes

• Optimize processes related to utilization management, care coordination, and claims review.
• Align medical management practices with industry standards and legal requirements.

Risk Mitigation

• Identify potential risks related to non-compliance and develop mitigation strategies.
• Ensure adherence to accreditation standards from organizations such as NCQA.

Support Organizational Strategy

• Provide expert advice on integrating regulations into strategic planning for healthcare delivery.
• Assist in developing training programs for staff to understand regulatory requirements.

Cost Control and Efficiency

• Reduce unnecessary healthcare expenditures by ensuring accurate utilization reviews and approvals.
• Enhance operational efficiency by standardizing regulatory workflows.
• Support and deliver regulatory reporting and performance initiatives.

Expertise in a Complex Environment

• Healthcare regulations are complex and constantly evolving; a specialist ensures the organization stays informed and adaptable.
• Provide leadership in audits and reviews by regulatory bodies.

Improve Member Outcomes and Satisfaction

• Develop policies that prioritize quality care while meeting regulatory requirements.
• Ensure compliance with member rights regulations to enhance trust and satisfaction.

Education:

• Bachelor’s degree in bachelor’s in nursing (BSN) healthcare administration, nursing, public health, or a related field preferred
• Minimum 3–5 years of experience in medical management, compliance, or regulatory affairs in a healthcare setting.
• Active Nursing licensure in the commonwealth of Pennsylvania preferred

Skills/Abilities:

• Proficient in Microsoft Office (Microsoft Word, Microsoft Excel, Microsoft PowerPoint, Microsoft Access and Visio). 
• Excellent organizational, written and oral communication skills. 
• Excellent interpersonal skills. 
• Ability to prioritize work, meet deadlines and work independently. 
• Ability to interact with staff as a team player. 
• Able to deal with sensitive data in a highly confidential manner.
• In-depth knowledge of healthcare regulations and standards (e.g., HIPAA, CMS, NCQA).
• Strong analytical and problem-solving skills.
• Excellent attention to detail.
• Ability to communicate complex regulatory information clearly.
• Certified Professional in Healthcare Quality (CPHQ), Certified Compliance Professional (CCP), or similar credential preferred.

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Primary Location Address

901 Market Street, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200 undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.    

Jefferson is committed to providing equal educa­tional and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.