Clinical Quality Program Manager

WellSky

13d•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 scope of this job includes analyzing and presenting data to establish best practices across post-acute health care settings, including LTACHs, IRFs, SNFs, and Home Health facilities. We invite you to apply today and join us in shaping the future of healthcare!

Requirements

At least 4-6 years relevant work experience.
Experience leading quality improvement projects and committee work.
Bachelor's Degree or equivalent work experience.

Nice To Haves

Active, unrestricted license: 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 minimum, 1-2 years of working knowledge of NCQA UM accreditation standards.
Must be able to prioritize, plan and handle multiple tasks and demands simultaneously, with competing deadlines.
Excellent in manipulating and sorting data for analytics and reporting.
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 other CMS and NCQA requirements.
Understand how the UM Program is driven by the NCQA UM standards to ensure UM Program meets all NCQA requirements for accreditation.
Prepare and lead committee meetings on a monthly and quarterly basis, driven by NCQA requirements.
Prepare detailed quality reports, identify and analyze trends, and present findings to leadership with actionable recommendations.
Support implementing corrective action plans when scoring variances occur.
Support quality improvement project initiatives.
Prepare for regulatory, accreditation, and contractual audits, and contribute to the remediation and documentation of audit findings.
Perform other job duties as assigned.