Senior Quality Assurance Nurse Manager

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

📋 Description

• Design, implement, and oversee a comprehensive Clinical Quality Program that incorporates embedded QA processes across Utilization Management (UM), Case Management (CM), Care Navigation, Pharmacy, Clinical Stop Loss/Underwriting, and Clinical insights within Health Plan Operations.

• Collaborate with Vendor Oversight to guarantee that quality and compliance standards are maintained across all clinical vendors and partners.

• Drive continuous improvement initiatives to boost the effectiveness and consistency of clinical operations.

• Ensure adherence to state and federal regulations, including all pertinent CMS, URAC, and NCQA standards.

• Maintain oversight of all clinical licensure requirements for nursing and pharmacy.

• Create and uphold policies and procedures that comply with regulatory and accreditation standards.

• Prepare the organization for external assessments, audits, and accreditation surveys.

• Lead the monitoring, trending, and analysis of clinical performance data to pinpoint risks, guide strategy, and aid leadership decision-making.

• Develop and manage departmental KPIs, performance metrics, and benchmarking to evaluate program effectiveness and quality outcomes.

• Supervise the tracking and resolution of grievances, incident reports, and adverse events.

• Provide clear, data-driven insights to Clinical Operations Leadership regarding opportunities for enhancement.

• Collaborate with cross-functional leaders to integrate QA principles and processes throughout all clinical departments.

• Develop and conduct regular training sessions for clinical and operational staff on quality standards, compliance, and continuous improvement initiatives.

• Act as a resource and subject matter expert on clinical quality assurance, compliance, and accreditation standards.

⛳️ Requirements

• Active, unrestricted Registered Nurse (RN) license.

• Bachelor’s degree in Nursing (BSN) or a related field is preferred.

• Over 7 years of clinical experience, with a minimum of 3-5 years in quality assurance, compliance, or accreditation within a health plan, managed care, or healthcare operations environment.

• At least 3 years of leadership experience.

• Profound understanding of UM/CM processes, regulatory requirements, and accreditation standards (URAC, NCQA, CMS).

• Strong analytical and problem-solving abilities with a proven track record of converting data into actionable insights.

🏝️ Benefits

• Coverage for alternative medicine.

• Flexible PTO.

• Up to 16 weeks of paid parental leave.

• Paid holidays.

• A 401k program.

• Transportation perks.

• Education reimbursement.

• 2 days of paid paw-ternity leave.