Clinical Quality Program Manager

WellSky

3d•Remote

About The Position

This job is responsible for ensuring compliance with WellSky's Utilization Management and Quality Improvement Program by serving as a clinical expert on state and federal regulations. The role analyzes and presents data to establish best practices across post-acute health care settings, including LTACHs, IRFs, SNFs, and Home Health facilities. It also supports performance measurement, quality improvement, regulatory compliance, and accreditation activities.

Requirements

At least 4–6 years of relevant work experience.
Experience leading quality improvement projects and committee work.
Bachelor's degree or equivalent work experience.
Must be able to prioritize, plan, and handle multiple tasks and demands simultaneously with competing deadlines.
Excellent ability to manipulate and sort data for analytics and reporting.
Must be able to sit and view a computer screen for extended periods.
Willingness to work additional or irregular hours as needed.
Applicants for U.S.-based positions must be legally authorized to work in the United States; employment eligibility will be verified at hire.

Nice To Haves

Active, unrestricted license as an RN, PT, OT, or SLP, with a bachelor's degree in a related field or a combination of education and experience that includes pertinent clinical experience and advanced working knowledge of CMS standards and guidelines.
At least 1–2 years of working knowledge of NCQA UM accreditation standards.
Prior experience owning client compliance SLAs and ensuring success in meeting SLA requirements.

Responsibilities

Facilitate activities related to performance measurement and outcomes.
Ensure the organization meets CMS, NCQA, and other regulatory standards, stay updated on relevant regulatory changes, and support their integration into practices.
Generate and validate reports to monitor performance across health plan contracts, ensuring accuracy and alignment with requirements.
Conduct regular audits of UM decisions, case documentation, turnaround times, and adherence to CMS and NCQA requirements.
Ensure the UM Program meets NCQA requirements for accreditation by understanding how it is driven by NCQA UM standards.
Prepare and lead monthly and quarterly committee meetings driven by NCQA requirements.
Prepare detailed quality reports, identify and analyze trends, and present findings to leadership with actionable recommendations.
Support implementation of corrective action plans when scoring variances occur.
Support quality improvement project initiatives.
Prepare for regulatory, accreditation, and contractual audits, and contribute to remediation and documentation of audit findings.
Perform other job duties as assigned.
Work in accordance with applicable security policies and procedures to safeguard company and client information.