The Clinical Quality Program Manager adheres to WellSky's Utilization Management Program Description and Quality Improvement Program requirements and serves as a clinical subject matter expert on relevant regulatory state and federal requirements under the Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and other relevant governing bodies. The Manager drives adherence to the Utilization Management Program Description and Quality Improvement Program requirements by organizing, analyzing, and presenting data so that information can be used to consistently apply clinical guidance across the organization and set best practice standards across the various lines of business that manage post-acute health care settings such as: Long Term Acute Care Hospitals (LTACHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs), and Home Health facilities (HH). The Clinical Quality Program Manager will participate and/or prepare for regulatory accreditation and contractual audits (including CMS program audits, CMS mock audits, CMS data validation audits, OIG audits, WellSky's NCQA accreditation audits, health plan partner NCQA accreditation audits and health plan partner delegation oversight audits).
A day in the life!
Key Responsibilities:
- Coordinates accreditation and regulatory requirement activities related to performance measurement and outcomes on behalf of the organization.
- Responsible for developing and overseeing WellSky's UM internal audit protocol, ensuring adherence to regulatory (CMS) requirements, accreditation (NCQA) standards, contractual obligations, and consistency in clinical documentation and decision-making.
- Develops performance improvement plans and oversees the clinical quality improvement activities/projects to improve the quality of care for members.
- Generate and perform data validation checks on monthly/quarterly/ad hoc universe reports (ODAG and Part C) for each delegated health plan contract as indicated per contract.
- Participate in, prepare for, and support regulatory, accreditation and contractual audits.
- Responsible for the development and maturation of UM policies and Procedures.
- Responsible for ongoing monitoring and remediation of post-hire primary source verification of clinical licenses, certifications, and board actions.
- Perform other duties and responsibilities as required, assigned, or requested.
Do you have what it takes?
Required Qualifications:
- Registered Nurse, Occupational Therapist, or Physical Therapist with a bachelor’s degree in a related field or a combination of education and experience including pertinent clinical experience with an understanding of CMS standards and guidelines.
- At least 8 years of relevant experience in healthcare quality management, utilization management, or related roles.
Do you stand above the rest?
Preferred Requirements:
- Ability to manage multiple competing priorities and tasks.
- Excellent written, oral, and interpersonal communication skills
- Excellent analytical and data interpretation skills.
- Utilization management, utilization review, or case management experience in a health care setting is highly preferred.
- Ability to manipulate and sort data for analytics and reporting.
- Demonstrated ability to manage external vendors and clients.
- Experience with CMS and/or NCQA audits is highly preferred.
#LI-PG1#LI-HybridAdditional job expectations applicable to this position include:
- Willingness to work additional or irregular hours as needed
- Working in accordance with corporate and organizational security policies and procedures
- Performing other responsibilities as assigned
WellSky is where independent thinking and collaboration come together to create an authentic culture. We thrive on innovation, inclusiveness, and cohesive perspectives. At WellSky you can make a difference.WellSky provides equal employment opportunities to all people without regard to race, color, national origin, ancestry, citizenship, age, religion, gender, sex, sexual orientation, gender identity, gender expression, marital status, pregnancy, physical or mental disability, protected medical condition, genetic information, military service, veteran status, or any other status or characteristic protected by law.
WellSky is proud to be a drug-free workplace.Applicants for U.S.-based positions with WellSky must be legally authorized to work in the United States. Verification of employment eligibility will be required at the time of hire. Certain client-facing positions may be required to comply with applicable requirements, such as immunizations and occupational health mandates.Here are some of the exciting benefits full-time teammates are eligible to receive at WellSky:
- Excellent medical, dental, and vision benefits
- Mental health benefits through TelaDoc
- Prescription drug coverage
- Generous paid time off, plus 13 paid holidays
- Paid parental leave
- 100% vested 401(K) retirement plans
- Educational assistance up to $2500 per year
