Manager- Quality & Acc.

MAJOR RESPONSIBILITIES

Support the business in achieving the goals of the Quality Department through the following responsibilities:

•    Leads the Quality Management Program, including annual program evaluation, quality improvement initiatives, KPI development, performance monitoring, and implementation of continuous process improvements. 

•    Identifies compliance, accreditation, contractual, and operational risks; conducts root cause analyses; develops corrective action plans; monitors effectiveness of interventions; and escalates significant issues as appropriate. 

•    Develops, implements, and oversees quality audit programs for clinical and physician review activities, including IRR audits, adverse determination reviews, and data integrity audits, ensuring alignment with contractual, regulatory, and accreditation requirements. 

•    Ensures audit findings are accurate, consistent, defensible, and supported by standardized methodologies, appropriate sampling techniques, and regulatory requirements. 

•    Maintains expertise in utilization management workflows, policies, and operational processes to ensure meaningful oversight and auditing activities. 

•    Partners with operations, clinical leadership, compliance, education, IT, and other stakeholders to resolve deficiencies, improve processes, and sustain corrective actions. 

•    Maintains readiness for accreditation surveys, client audits, and regulatory reviews by monitoring changing requirements, updating policies and audit criteria, maintaining evidence repositories, and coordinating survey activities. 

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

•    Leads preparation for external audits, surveys, and delegated oversight reviews conducted by clients, regulators, and accrediting organizations. 

•    Leads Quality Management and Compliance Committees and provides governance, oversight, reporting, and recommendations to organizational leadership. 

•    Maintains Quality Management Program documentation, including program descriptions, work plans, annual evaluations, committee records, quality improvement projects, and required reports. 

•    Analyzes and presents quality, compliance, accreditation, complaint, utilization management, and audit data to leadership, committees, clients, and external stakeholders. 

•    Oversees complaint investigations, trend analysis, reporting, and corrective actions in accordance with contractual, accreditation, and regulatory requirements. 

•    Oversees fraud, waste, and abuse reporting activities and ensures appropriate reporting and documentation in accordance with company policies and contractual requirements. 

•    Oversees regulatory and accreditation-required education tracking, exclusion monitoring, clinician credentialing, licensure verification, and credentialing record maintenance. 

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

•    Ensures compliance with all applicable federal and state regulations, accreditation standards, company policies, privacy requirements, and professional standards. 

•    Provides exceptional service to internal and external stakeholders and performs other duties as assigned.

Function: Quality Assurance
Experience Level: Mid-Senior Level