Quality Assurance Manager – Clinical Systems

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

📋 Description

• Provide leadership guidance on the appropriate and efficient utilization of decision-making tools for management activities, including staff training.

• Oversee multiple teams and resources.

• Collaborate with Clinical Operations and other CareOregon teams to integrate and promote organizational activities and objectives across all business lines.

• Lead the planning of the department and manage internal operations along with vendor transactional quality assurance processes.

• Develop and oversee quality assurance reports, dashboards, workflows, testing programs, clinical content, documentation, and verification tools.

• Ensure clinical systems comply with regulatory, contractual, and organizational standards for Medicare and Medicaid.

• Analyze data to pinpoint improvement opportunities and suggest process enhancements.

• Execute strategies to ensure compliance with both internal and external corrective action plans.

• Maintain compliance records and monitor regulatory expectations and health plan quality-operation standards.

• Utilize quality improvement and change management methodologies, including root cause analysis and Plan/Do/Study/Act.

• Prepare internal business reviews and presentations.

• Act as a clinical resource for both internal and external stakeholders and provide training on clinical content.

• Collaborate with Medical Directors and Clinical Operations leadership on organizational criteria.

• Develop project plans, track tasks, and ensure timely delivery of clinical content.

• Participate in internal and external workgroups, meetings, and audits.

• Engage stakeholders in performance improvement initiatives and collaborate with other Quality Assurance leaders.

• Recruit, hire, supervise, train, coach, motivate, and evaluate employees.

• Set team direction, staffing plans, goals, expectations, and performance standards.

• Perform supervisory responsibilities with Human Resources and support employee development.

• Operate in alignment with CareOregon’s mission, vision, values, equity, diversity, inclusion, policies, procedures, and compliance requirements.

⛳️ Requirements

• Current unrestricted Registered Nurse (RN) license for the State of Oregon.

• A minimum of 5 years of experience in health plan quality operations, including member rights, quality assurance, and/or utilization management.

• At least 2 years of experience in a supervisory role, or a minimum of 1 year of supervisory experience with completion of CareOregon’s Aspiring Leaders Program (preferred).

• Proficiency in nationally accepted clinical guidelines, such as InterQual or MCG (preferred).

• Experience in developing quality and testing programs, processes, and procedures from the ground up (preferred).

• Familiarity with applications and front and back-end system testing and technologies across multiple operating systems and environments (preferred).

• Background in clinical content creation or medical writing (preferred).

• Experience with training and onboarding (preferred).

• Experience in directing vendor testing (preferred).

• Strong understanding of health plan operations.

• Knowledge of health plan regulatory requirements for Medicaid and Medicare managed care.

• Awareness of utilization management principles.

• Understanding of managed care concepts and principles.

• Familiarity with organizational improvement principles and practices.

• Knowledge of organizational change principles and ability to function as a change agent.

• Understanding of quality improvement concepts, principles, and practices.

• Basic knowledge of software development phases.

• Comprehensive skills in program development, management, and evaluation.

• Strong project management, statistical, analytical, problem-solving, prioritization, and organizational skills.

• Ability to establish test requirements and identify root causes.

• Capability to work independently as well as collaboratively within a team, manage multiple projects, meet deadlines, and perform under pressure.

• Excellent written, verbal, spoken, presentation, interpersonal, and leadership abilities.

• Skills in negotiation, conflict resolution, collaboration, and consensus building.

• Ability to coach, mentor, and inspire staff working both onsite and remotely.

• Capability to lead and influence change and achieve results.

• Ability to work effectively with individuals and groups from diverse backgrounds.

• Capability to see, read, and perform repetitive finger and wrist movements for at least 6 hours per day.

• Ability to hear and speak clearly for at least 3-6 hours per day.

🏝️ Benefits

• Bonus opportunity; SIP target of 5% annually.

• Medical, dental, vision, life, AD&D, and disability insurance.

• Health savings account.

• Flexible spending account(s).

• Lifestyle spending account.

• Employee assistance program.

• Wellness program.

• Discounts and various supplemental benefits, including voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, and 529 College Savings.

• Retirement plan with employer contributions.

• Paid time off (PTO).

• Paid State Sick Time.

• Paid holidays.

• Volunteer time.

• Jury duty leave.

• Bereavement leave.

• Remote work from home.

• 401(k) contributions for non-benefits-eligible employees.