Manager – Quality & Acc.

This is a fully remote position, open to applicants in Texas.

📋 Description

• Direct the Quality Management Program, which encompasses annual evaluations, quality enhancement initiatives, KPI development, performance monitoring, and ongoing process improvements.

• Recognize compliance, accreditation, contractual, and operational risks; perform root cause analyses; create corrective action plans; assess the effectiveness of interventions; and escalate critical issues.

• Create, implement, and supervise quality audit programs for clinical and physician review processes, including IRR audits, adverse determination assessments, and data integrity audits.

• Ensure that audit findings are precise, consistent, defensible, and backed by standardized methodologies, sampling techniques, and regulatory mandates.

• Maintain expertise in utilization management workflows, policies, and operational processes for effective oversight and auditing.

• Collaborate with operations, clinical leadership, compliance, education, IT, and other stakeholders to address deficiencies and uphold corrective measures.

• Ensure preparedness for accreditation surveys, client audits, and regulatory reviews by tracking requirements, revising policies and audit criteria, maintaining evidence repositories, and coordinating survey activities.

• Supervise URAC and NCQA accreditation initiatives, including interpretation of standards, gap assessments, survey preparation, application management, and response coordination.

• Lead the preparation for external audits, surveys, and delegated oversight evaluations.

• Direct Quality Management and Compliance Committees, providing governance, oversight, reporting, and recommendations to organizational leadership.

• Maintain documentation for the Quality Management Program, including program descriptions, work plans, annual evaluations, committee records, quality improvement projects, and necessary reports.

• Analyze and present data on quality, compliance, accreditation, complaints, utilization management, and audits to leadership, committees, clients, and external stakeholders.

• Oversee investigations of complaints, trend analyses, reporting, and corrective actions.

• Manage reporting activities related to fraud, waste, and abuse, including associated documentation.

• Supervise education tracking required by regulations and accreditation, exclusion monitoring, clinician credentialing, licensure verification, and maintenance of credentialing records.

• Offer leadership, coaching, performance management, workload balance, succession planning, and professional growth for the Quality team members.

• Ensure adherence to federal and state regulations, accreditation standards, company policies, privacy requirements, and professional standards.

• Deliver exceptional service to internal and external stakeholders while performing other assigned tasks.

⛳️ Requirements

• Graduate from an accredited nursing program.

• Active, unrestricted RN license is required.

• A minimum of 5 years of utilization management experience in a health plan, UM vendor, or delegated UM organization, including prior authorization.

• At least 3 years of experience in quality, audit, compliance, accreditation, or quality management, including audit programs, KPI reporting, and corrective action planning.

• Minimum of 2 years of progressive leadership experience in a managed care setting with responsibilities for team performance and outcomes.

• Proven success in developing KPIs, conducting root cause analyses, and driving measurable performance improvements.

• Familiarity with URAC and/or NCQA accreditation standards and requirements for quality management programs.

• Understanding of Medicare, Medicaid, and commercial utilization management regulations, including CMS and state utilization review requirements.

• Experience in leading initiatives aimed at improving quality, productivity, and performance.

• Strong leadership, facilitation, communication, critical thinking, and organizational abilities.

• Capability to excel in a fast-paced, dynamic environment and collaborate effectively across teams.

• HIPAA-compliant remote workspace with reliable high-speed internet access.

• Ability to use the telephone, sit, enter data, and view a PC screen for up to 8 hours.

• Skill in prioritizing tasks in a multi-tasking environment.

• BSN, MSN, or another bachelor's degree is preferred.

• Experience participating in accreditation surveys or delegation audits is preferred.

• Previous quality management experience within a health plan or delegated utilization management organization is strongly preferred.

• CPHQ certification is preferred; training in Lean Six Sigma or other process improvement methodologies is a plus.

🏝️ Benefits

• Medical, dental, and vision insurance.

• Paid time off (PTO), holidays, and sick leave.

• 401(k) with company match or other retirement plan.

• Life and AD&D Insurance.

• Employee Assistance Program.

• Performance-based bonuses, incentive pay, or commissions may be available.

• Reasonable accommodations for individuals with disabilities and sincerely held religious beliefs.