Compliance Nurse

IntePros is an established, woman-owned, privately-held technology and business services consulting agency committed to building long-term relationships and helping more companies leverage the power of a more diverse workforce.

Job Title: RN Care Management Coordinator – Compliance Specialist (Remote, Tri-State Area)** Location: Remote (Candidates must reside in the Tri-State Area) License Requirement: PA Licensed Registered Nurse (RN) only — No LPN candidates Job Summary: The Compliance Specialist plays a critical role in ensuring that Utilization Management (UM) operations comply with all relevant regulations and standards, including NCQA, CMS, and various state requirements. This role involves monitoring the medical review process to confirm appropriate medical necessity determinations, accurate application of InterQual criteria and medical policies, and proper documentation for referral and letter generation. The Compliance Specialist also coordinates business operations related to NCQA activities such as surveys and document maintenance, along with supporting various projects and initiatives.

Evaluate and interpret regulations and standards (NCQA, CMS, and state-specific), ensuring appropriate controls are implemented and maintained. Recommend and oversee the adoption of new controls as needed. Conduct monthly compliance audits and report findings, trends, and potential issues affecting operational efficiency and quality to management and directors. Perform ongoing sample case reviews to verify correct application of InterQual criteria, medical policies, and appropriate referrals to Medical Directors. Ensure that submitted information is accurate and facilitates informed decision-making. Ensure clinical staff documentation within the medical management system is thorough, accurate, and meets regulatory standards for clear and understandable member communications. Serve as a resource for both internal teams and external stakeholders, providing professional, timely, and effective communication. Support NCQA-related business operations, including survey preparation and annual documentation updates. Perform additional duties as assigned.