Quality Manager

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

📋 Description

• Direct the Quality Management Program, encompassing annual evaluations, quality enhancement initiatives, KPI formulation, performance tracking, and ongoing process enhancements.

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

• Design, execute, and manage quality audit programs for clinical and physician review tasks, including IRR audits, adverse determination assessments, and data integrity audits.

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

• Supervise utilization management workflows, policies, and operational processes for quality oversight and auditing.

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

• Maintain preparedness for accreditation surveys, client audits, and regulatory reviews.

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

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

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

• Keep up-to-date documentation of the Quality Management Program, 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.

• Oversee investigations into complaints, trend analysis, reporting, and corrective actions.

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

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

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

• Ensure adherence to applicable regulations, accreditation standards, company policies, privacy mandates, and professional standards.

• Deliver exceptional service to both internal and external stakeholders and perform other assigned responsibilities.

⛳️ Requirements

• Graduate from an accredited nursing program.

• Active, unrestricted RN license is required.

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

• More than 3 years of experience in quality, audit, compliance, accreditation, or quality management, encompassing audit programs, KPI reporting, and corrective action planning.

• At least 2 years of progressive leadership experience in a managed care setting with accountability for staff performance and team results.

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

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

• Knowledge of 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 dynamic, fast-paced environment and collaborate effectively across teams.

• HIPAA-compliant remote working environment with dependable high-speed internet.

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

• Ability to prioritize tasks in a multi-tasking environment.

🏝️ Benefits

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

• Medical, dental, and vision insurance.

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

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

• Life and AD&D Insurance.

• Employee Assistance Program.

• Equal Opportunity Employer.

• Reasonable accommodations for disabilities and sincerely held religious beliefs.