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Job Description
UM Compliance Specialist Imperial Management Administrators Services Inc - 2.9 Pasadena, CA Job Details $26 - $29 an hour 1 hour ago Qualifications Customer communication Writing skills High school diploma or GED Computer skills Full Job Description 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).
