Under the general supervision of the UM/QI Director, the Regulatory Compliance Nurse Specialist is responsible The Regulatory Compliance Nurse Specialist will be responsible for supporting the implementation and maintenance of key projects aimed at improving utilization management (UM) procedures and processes and to ensure that the UM Department is meeting compliance with CMS, DHS, DMHC and Gold Coast Health Plan and other managed care organization regulations and contractual  requirements for UM delegated activities. The ideal candidate will have experience with project management, utilization management, and care coordination tools and methodologies. The Regulatory Compliance Nurse Specialist will be key in performing internal auditing and UM administrative compliance activities in the Utilization Management Department. Prepare UM/QM activity progress reports for oversight entities Attend Committee Meetings related to the UM/QA Department. Assist with developing and/or revising annually and on an as needed basis, UM Program, Policies and Procedures, and Work Plans. Prepares quarterly and annual work plan evaluations, to measure progress of work plan activities. Prepares activities for due diligence and annual audits for oversight entity UM contractual activities. Prepare cases for internal audits. Prepared agenda, materials for webinars and UM staff in-services regarding regulatory updates and policy and procedure revisions and process improvement. Prepare for delegated oversight Health Plan audits. Develop and provide training on regulatory and delegation compliance standards and authorization processes. Attends Clinicas network, internal QA meetings, and Health Plan collaborative committees as needed or assigned. Conduct IRR audits on non-MD staff Serves as a liaison between Clincas UM and oversight entities for investigation and resolution of identified issues and deficiencies. Monitoring of regulatory databases for new updates and amends policies and procedures to reflect timely implementation of processes for compliance. Track contracted Health Plan reporting and corrective action plans to assure compliance with standards Identify compliance problems and formulate recommendations for corrective action Utilizes monthly reports to assess over and under-utilization management trends and to ensure quality indicators are being met. Monitors the use of handling confidentiality. Interfaces with other departments in regards with Health Plan contractual and regulatory standards to ensure operational adherence. Develop and present reports as needed to the Board of Directors, and Medical Services Committees Other duties as assigned by the Director of UM/QA