Manager, Quality & Acc.

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

📋 Description

• Direct the Quality Management Program, which encompasses annual assessments, quality enhancement initiatives, KPI formulation, performance tracking, and ongoing process improvements.

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

• Design, implement, and manage quality audit programs for clinical and physician review activities, which include IRR audits, adverse determination reviews, and data integrity audits.

• Ensure the accuracy, consistency, defensibility, and support of audit findings through standardized methodologies, suitable sampling, and adherence to regulatory requirements.

• Maintain expertise in utilization management workflows, policies, and operational processes.

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

• Prepare for accreditation surveys, client audits, and regulatory reviews.

• Oversee URAC and NCQA accreditation efforts, including standards interpretation, gap assessments, survey preparation, application management, and response coordination.

• Lead preparations for external audits, surveys, and delegated oversight reviews.

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

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

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

• Supervise complaint investigations, trend analysis, reporting, and corrective measures.

• Oversee reporting activities related to fraud, waste, and abuse, along with the associated documentation.

• Manage education tracking, exclusion monitoring, clinician credentialing, licensure verification, and maintenance of credentialing records.

• Provide leadership, coaching, performance management, workload balancing, succession planning, and professional growth for members of the Quality team.

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

• Deliver exceptional service to both internal and external stakeholders and perform additional assigned duties.

⛳️ Requirements

• Graduate from an accredited nursing program.

• Active, unrestricted RN license is a must.

• 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, which includes audit programs, KPI reporting, and corrective action planning.

• A minimum of 2 years of progressive leadership experience in a managed care setting with accountability for staff performance and team outcomes.

• Proven track record in developing KPIs, conducting root cause analyses, and fostering measurable performance improvements.

• Working knowledge of URAC and/or NCQA accreditation standards as well as quality management program requirements.

• Familiarity with Medicare, Medicaid, and commercial utilization management regulations, including CMS and state utilization review requirements.

• Experience in leading quality, productivity, and performance improvement initiatives.

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

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

• Reliable high-speed internet connection.

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

• Proficient in prioritizing tasks within a multi-tasking environment.

• Preferred: BSN, MSN, or other bachelor's degree.

• Preferred: Participation in accreditation surveys or delegation audits.

• Preferred: CPHQ certification; Lean Six Sigma or other process improvement training is a plus.

🏝️ Benefits

• Medical, dental, and vision insurance.

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

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

• Life and AD&D Insurance.

• Employee Assistance Program.

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

• HIPAA-compliant remote work location.