Clinical Programs Monitoring Specialist

GENERAL DESCRIPTION: Responsible for the ongoing monitoring of all elements of the Special Needs Plan Care Coordination (SNP-CC) as needed to comply with regulatory requirements and quality indicators. Evaluates care coordination frameworks, identifies risks and improvement opportunities, supports audit readiness, and works closely across departments to ensure compliance and operational performance. ESSENTIAL FUNCTIONS: • Establishes an ongoing monitoring program to ensure compliance with the minimum requirements related to Special Needs Plan Care Coordination (SNP-CC), including completion and timeliness of core elements like Health Risk Assessments (HRAs), Individualized Care Plans (ICPs) and other care coordination related elements. • Evaluates continuously the company’s established care coordination framework to identify areas of improvement or compliance vulnerability and recommend corrective action plans (CAPs). • Interprets trends, data, and quality metrics to identify enterprise-wide risks or opportunities for improvement. Identify new data collection opportunities. • Presents performance results and recommendations to executive leadership and ensure they are awarded visibility into the compliance and regulatory risks. • Maintains internal logs, dashboards, and other documentation related to the Special Needs Plan Care Coordination (SNP-CC) elements updated. • Identifies possible best practices that may be established and recommends improvements to care coordination workflows and processes. • Identifies and reports on technologies and resources that may improve the overall results. • Supports Centers for Medicare and Medicaid Services (CMS) audits, mock audits, Compliance monitoring and other evaluations performed by regulatory and accreditation entities including the support for the development of audit-ready documentation. • Trains impacted staff on changes in regulations or internal processes to ensure operational efficiency and regulatory compliance. • Works closely with the IT Department to assist in the development of advanced analytics and reporting tools to monitor performance. • Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices. • May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document. MINIMUM QUALIFICATIONS: Education and Experience: Bachelor’s degree in Business Administration, Health Services Administration, Nursing, Public Health, or a related field. At least three (3) years of experience in clinical quality monitoring, care plan auditing, or healthcare compliance, preferably within the health insurance industry or managed care environments. “Proven experience may be replaced by previously established requirements.” Certifications / Licenses: N/A Other: Strong understanding of Special Needs Plan Care Coordination (SNP CC) requirements and Centers for Medicare and Medicaid Services (CMS) regulations is considered a plus. Languages: Spanish – Intermediate (comprehensive, writing, and verbal) English – Advanced (comprehensive, writing, and verbal)