Quality Manager Jobs

About The Position

Requirements

• Graduate of an accredited nursing program; active, unrestricted RN license required.
• 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 multi-task 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.
• 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 methods, appropriate sampling, 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 insurance
• Dental insurance
• Vision insurance
• Paid time off (PTO)
• Holidays
• Sick leave
• 401(k) with company match or other retirement plan
• Life and AD&D insurance
• Employee Assistance Program
• Role may be eligible for performance-based bonuses, incentive pay, or commissions