Clinical Quality Manager - Remote in PA

Primary Responsibilities

• Oversee the implementation of plan's quality improvement program (QAPI)
• Work to coordinate the work with the clinical, operations, and network teams to improve HEDIS and NCQA performance and to close gaps in care
• Manage Quality work plan programs and activities
• Collaborate across local and national business segments to achieve goals and targets
• Develop and maintain positive relationships with external state organizations within the scope of Quality Management
• Continuously monitor HEDIS, NCQA, and state performance measure results and adjust programs to ensure targeted goals
• Serve as panelist for grievance and appeal hearings
• Support Performance Improvement Projects, accreditation, and regulatory audits as needed
• Develop and mentor quality department staff
• Oversee quality quarterly review meetings with state partners

Required Qualifications

• RN License in the state of Pennsylvania
• 2+ years of experience with HEDIS and NCQA - this includes PIP and quality improvement project experience
• 1+ years of leadership/management experience (e.g., Review work of others, serve as an expert in their field, serve as a mentor and leader, lead functional or segment teams or projects, motivate and inspire team members)
• Experience with outside audit organizations such as External Quality Review Organizations (EQROs)
• Experience with managed care and insurance industry
• Experience in writing reports and analyzing performance data
• Experience creating detailed reports and project management
• Reside in PA

Preferred Qualifications

• 2+ years demonstrated Management experience with responsibility for team performance management
• Quality improvement experience within a health plan- CPHQ Certification
• Experience with excel (working with pivot tables) and creating PPT presentations
• Medicaid experience
• Clinical experience / background
• Change management experience and demonstrated skills
• Proven ability to make independent decisions
• Proven ability to complete various deliverables utilizing scholarly writing and AI technology

Pay and Benefits

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).

The salary for this role will range from $91,700 - $163,700 annually based on full-time employment.

We comply with all minimum wage laws as applicable.