The Clinical Quality Program Manager will play a crucial role in supporting WellSky’s Utilization Management and Quality Improvement Programs. Acting as a clinical subject matter expert, the Quality Manager will ensure adherence to relevant state and federal regulatory requirements under the Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and other governing bodies. This position focuses on analyzing and presenting data to apply clinical guidance consistently across the organization, enhancing quality standards in post-acute healthcare settings, including Long Term Acute Care Hospitals (LTACHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs), and Home Health facilities (HH).
A day in the life!
Key Responsibilities
- Support Accreditation and Compliance: Assist in coordinating accreditation and regulatory requirement activities related to performance measurement and outcomes, ensuring compliance with established standards.
- Audit Protocols: Contribute and adhere to the development and oversight of WellSky's internal audit protocols, ensuring adherence to CMS requirements, NCQA standards, contractual obligations, and consistency in clinical documentation.
- Quality Improvement Initiatives: Develop and support clinical quality improvement projects aimed at enhancing the quality of care for members.
- Data Validation: Generate and perform data validation checks on monthly, quarterly, and ad hoc reports for each delegated health plan contract, ensuring accuracy as indicated per contract.
- Audit Preparation Support: Participate in and prepare for regulatory, accreditation, and contractual audits, providing necessary data and documentation.
- Policy Development Support: Assist in the development and maturation of UM policies and procedures.
- License Monitoring: Support ongoing monitoring and verification of clinical licenses, certifications, and board actions as required.
- Other Duties: Perform additional duties and responsibilities as assigned or requested.
Qualifications
Required:
- Registered Nurse, Occupational Therapist, or Physical Therapist with a bachelor’s degree in a related field, or a combination of education and experience that includes pertinent clinical experience and an understanding of CMS standards and guidelines.
- At least 5 years of relevant experience in healthcare quality management, utilization management, or related roles.
- Ability to manage multiple competing priorities and tasks effectively.
- Strong written, oral, and interpersonal communication skills.
- Demonstrated ability to collaborate with external vendors and clients.
A Do you stand above the rest?
Preferred:
- Experience with CMS and/or NCQA audits.
- Proficiency in manipulating and sorting data for analytics and reporting.
- Excellent analytical and data interpretation skills.
- Experience in utilization management, utilization review, or case management in a healthcare setting is highly preferred.
Additional 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
