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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

• None required.