Manager- Quality & Acc.

WNS Global Services • Houston, TX

10d • $100,000 - $125,000 • Remote

About The Position

The Manager- Quality & Acc. supports the business in achieving the goals of the Quality Department by leading quality management, audit, compliance, and accreditation activities. The role oversees the Quality Management Program, including annual evaluations, quality improvement initiatives, KPI development, performance monitoring, and continuous process improvement. It identifies compliance, accreditation, contractual, and operational risks; performs root cause analyses; develops corrective action plans; and monitors the effectiveness of interventions.

The position develops and oversees audit programs for clinical and physician review activities, including IRR audits, adverse determination reviews, and data integrity audits. It maintains expertise in utilization management workflows and ensures audit findings are accurate, consistent, defensible, and aligned with applicable standards. The manager partners with operational, clinical, compliance, education, IT, and other stakeholders to address deficiencies and sustain improvements.

The manager maintains readiness for accreditation surveys, client audits, and regulatory reviews; oversees URAC and NCQA accreditation activities; and leads preparations for external audits, surveys, and delegated oversight reviews. The role leads Quality Management and Compliance Committees, maintains program documentation, analyzes and presents quality and compliance data, and oversees complaint investigations, fraud, waste, and abuse reporting, education tracking, exclusion monitoring, clinician credentialing, and licensure verification. It also provides leadership, coaching, performance management, workload balancing, succession planning, and professional development for Quality team members while ensuring adherence to applicable regulations, accreditation standards, company policies, privacy requirements, and professional standards.

The role is performed from a HIPAA-compliant remote location with reliable high-speed internet. The position requires using a telephone, sitting, entering data, and viewing a PC screen for up to eight hours, as well as prioritizing work in a multitasking environment.

Requirements

• Graduate of an accredited nursing program.
• Active, unrestricted RN license.
• At least 5 years of utilization management experience in a health plan, UM vendor, or delegated UM organization, including prior authorization.
• At least 3 years of quality, audit, compliance, accreditation, or quality management experience, including audit programs, KPI reporting, and corrective action planning.
• At least 2 years of progressive leadership experience in a managed care environment with responsibility for staff performance and team outcomes.
• Demonstrated success developing KPIs, conducting root cause analyses, and driving measurable performance improvement.
• Knowledge of Medicare, Medicaid, and commercial utilization management regulations, including CMS and state utilization review requirements.
• Experience leading quality, productivity, and performance improvement initiatives.
• Strong leadership, facilitation, communication, critical thinking, and organizational skills.
• Ability to thrive in a fast-paced, evolving environment and collaborate effectively across teams.
• Ability to use the telephone, sit, enter data, and view a PC screen for up to 8 hours.
• Ability to prioritize in a multitasking environment.
• Reliable high-speed internet and a HIPAA-compliant remote location.

Nice To Haves

• BSN, MSN, or another bachelor's degree preferred.
• Working knowledge of URAC and/or NCQA accreditation standards and quality management program requirements; participation in accreditation surveys or delegation audits preferred.
• Prior quality management experience within a health plan or delegated utilization management organization strongly preferred.
• CPHQ certification preferred.
• Lean Six Sigma or other process improvement training is a plus.

Responsibilities

• Lead the Quality Management Program, including annual program evaluation, quality improvement initiatives, KPI development, performance monitoring, and continuous process improvements.
• Identify compliance, accreditation, contractual, and operational risks; conduct root cause analyses; develop corrective action plans; monitor intervention effectiveness; and escalate significant issues as appropriate.
• Develop, implement, and oversee quality audit programs for clinical and physician review activities, including IRR audits, adverse determination reviews, and data integrity audits.
• Ensure audit findings are accurate, consistent, defensible, and supported by standardized methodologies, appropriate sampling techniques, and regulatory requirements.
• Maintain expertise in utilization management workflows, policies, and operational processes to support meaningful oversight and auditing.
• Partner with operations, clinical leadership, compliance, education, IT, and other stakeholders to resolve deficiencies, improve processes, and sustain corrective actions.
• Maintain readiness for accreditation surveys, client audits, and regulatory reviews by monitoring requirements, updating policies and audit criteria, maintaining evidence repositories, and coordinating survey activities.
• Oversee URAC and NCQA accreditation activities, including standards interpretation, gap assessments, survey preparation, application management, and response coordination.
• Lead preparation for external audits, surveys, and delegated oversight reviews conducted by clients, regulators, and accrediting organizations.
• Lead Quality Management and Compliance Committees and provide governance, oversight, reporting, and recommendations to organizational leadership.
• Maintain Quality Management Program documentation, including program descriptions, work plans, annual evaluations, committee records, quality improvement projects, and required reports.
• Analyze and present quality, compliance, accreditation, complaint, utilization management, and audit data to leadership, committees, clients, and external stakeholders.
• Oversee complaint investigations, trend analysis, reporting, and corrective actions in accordance with contractual, accreditation, and regulatory requirements.
• Oversee fraud, waste, and abuse reporting activities and ensure appropriate reporting and documentation in accordance with company policies and contractual requirements.
• Oversee regulatory- and accreditation-required education tracking, exclusion monitoring, clinician credentialing, licensure verification, and credentialing record maintenance.
• Provide leadership, coaching, performance management, workload balancing, succession planning, and professional development for Quality team members.
• Ensure compliance with applicable federal and state regulations, accreditation standards, company policies, privacy requirements, and professional standards.
• Provide exceptional service to internal and external stakeholders and perform other duties as assigned.

Benefits

• Medical, dental, and vision insurance.
• Paid time off (PTO), holidays, and sick leave.
• 401(k) with company match or other retirement plan.
• Life and AD&D Insurance.
• Employee Assistance Program.
• The role may be eligible for performance-based bonuses, incentive pay, or commissions.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: Associate degree