Manager- Quality & Acc.
Core
Leads the Quality Management Program, oversees audit programs for clinical and physician review activities, and ensures compliance with regulatory and accreditation requirements in a managed care environment.
Role type
Manager, Quality & Compliance
Builds
Quality management programs, audit findings, corrective action plans, and accreditation readiness.
Domain
Healthcare / Utilization Management / Quality Assurance
Required skills
Quality management program leadership, root cause analysis, audit program development, utilization management workflows, regulatory compliance, accreditation standards interpretation, team leadership, KPI development, complaint investigation, fraud/waste/abuse reporting, credentialing oversight.
Preferred skills
CPHQ certification, Lean Six Sigma, URAC/NCQA accreditation survey experience, Medicare/Medicaid/commercial UM regulations knowledge, prior health plan or delegated UM organization experience.
Technologies
None explicitly stated
Responsibilities
Lead annual program evaluation and continuous process improvements; conduct risk identification and corrective action planning; oversee clinical and physician review audits; maintain accreditation readiness (URAC/NCQA); lead quality committees; analyze and report quality/compliance data; oversee complaint and FWA reporting; manage team performance and development.
Seniority
Manager, hands-on leadership