Quality Assurance Manager

Department: Quality Assurance Reports To: Directors of Community Health & Operations Classification: Exempt Work Arrangement: Hybrid - California Based Schedule: Monday - Friday | 8:30 AM - 5:00 PM Compensation: 78k - 82k annually About Pacific Health Group Pacific Health Group (PHG) is committed to improving health outcomes by addressing the medical, behavioral, and social needs of the communities we serve. Through programs such as Enhanced Care Management (ECM), Community Supports (CS), Community Health Worker (CHW) services, Behavioral Health, and other community-based healthcare programs, PHG works collaboratively with health plans, providers, community organizations, and other partners to support whole-person care.Our work is grounded in accountability, collaboration, innovation, integrity, and a commitment to improving access to high-quality services for vulnerable and underserved populations. Position Summary The Quality Assurance (QA) Manager is responsible for the leadership, development, implementation, oversight, and continuous improvement of Pacific Health Group's organization-wide Quality Assurance program. This position provides quality oversight across PHG programs and operational departments, including Enhanced Care Management (ECM), Community Supports (CS), Community Health Worker (CHW) services, Behavioral Health, Revenue Cycle, Outreach, and other organizational functions as assigned. The QA Manager ensures that services, documentation, workflows, and operational practices align with applicable health plan requirements, contractual obligations, regulatory standards, internal policies and procedures, and established PHG quality expectations. The QA Manager leads routine and targeted audits, develops quality metrics and dashboards, identifies trends and systemic risks, oversees corrective action follow-up, strengthens operational workflows, and works collaboratively with department managers to improve quality, accuracy, consistency, and adherence to applicable requirements. This position provides direct leadership and oversight to assigned Quality Assurance personnel and serves as a key quality resource to the Directors of Community Health & Operations and departmental leadership. The QA Manager is expected to operate proactively and independently within the scope of the position. Quality concerns should be identified through established monitoring and auditing processes rather than solely through leadership escalation. Essential Duties And Responsibilities Quality Assurance Program Management Develop, implement, manage, and continuously improve PHG's organization-wide Quality Assurance programEstablish standardized quality expectations, audit methodologies, monitoring processes, scoring criteria, and reporting requirementsDevelop annual and ongoing quality monitoring plans based on organizational priorities, payer requirements, identified risks, audit findings, and performance trendsEnsure quality processes are consistently applied across applicable programs and departmentsEstablish clear standards for documentation quality, workflow adherence, operational accuracy, timeliness, and applicable quality requirementsEvaluate existing workflows and recommend improvements designed to reduce errors, strengthen accountability, and improve service deliveryMaintain Quality Assurance policies, procedures, audit tools, checklists, workflows, and standard operating proceduresEnsure QA processes evolve as payer, contractual, regulatory, program, and organizational requirements changeEstablish risk-based monitoring strategies that prioritize high-risk programs, requirements, workflows, or identified areas of concern Health Plan, County & External Audit Readiness Maintain organizational readiness for health plan audits, county reviews, monitoring activities, program reviews, and other external quality assessments within QA's scopeCoordinate preparation for external audits and reviewsReview applicable documentation and records in advance of scheduled audits when appropriateCoordinate with department leadership to ensure required materials are accurate, complete, organized, and availableMaintain centralized tracking of upcoming audits, requested documentation, submission deadlines, findings, and required responsesTrack external audit findings and required corrective actionsSupport development and coordination of responses to health plan, county, or external quality findingsMonitor completion of remediation activities following external reviewsMaintain organized records of audit requests, submissions, findings, responses, corrective actions, and supporting documentationIdentify trends across external reviews and recommend organization-wide improvements when appropriatePromptly communicate significant audit findings or risks to the Directors of Community Health & Operations Documentation & Program Quality Maintain working knowledge of documentation and quality requirements applicable toPHG's contracted programs and servicesMonitor adherence to established documentation timelines and quality standardsEvaluate whether documentation appropriately reflects services provided and established program requirementsIdentify documentation trends that may affect reimbursement, contractual performance, audit outcomes, member services, or quality of serviceCollaborate with program leadership to correct documentation deficiencies and strengthen workflowsCommunicate significant changes in quality or documentation requirements to affected departmentsDevelop standardized tools, checklists, and guidance to promote consistent documentation practicesPartner with Revenue Cycle when documentation deficiencies may affect billing or reimbursement while maintaining clear departmental ownership of Revenue Cycle functions Quality Team Leadership & Performance Management Provide direct supervision, leadership, coaching, and support to assigned Quality Assurance personnelEstablish clear individual and departmental performance expectations and KPIsAssign and monitor audit responsibilities, workloads, priorities, and deadlinesConduct regular one-on-one meetings and QA team meetingsMonitor staff productivity, audit accuracy, consistency, timeliness, and completion of assigned responsibilitiesConduct performance evaluations and provide ongoing coaching and professional developmentAddress performance deficiencies promptly and partner with Human Resources when appropriateEvaluate staffing levels and workload distribution based on organizational quality monitoring needsEnsure appropriate coverage and continuity of QA responsibilities during staff absencesDevelop QA staff competency in auditing, documentation review, quality standards, data analysis, root-cause analysis, and effective communicationFoster a culture of objectivity, accountability, professionalism, consistency, collaboration, and continuous improvement Audit Consistency & Calibration Establish standardized auditing methodologies and scoring expectations across the QA departmentConduct routine calibration sessions with QA personnel to promote consistent interpretation and application of audit standardsMonitor consistency between QA reviewers and identify areas requiring clarification or retrainingDevelop standardized audit guidance and reference materialsPeriodically review completed QA audits for accuracy and consistencyAddress significant variations in scoring or interpretationUpdate audit tools and guidance when requirements change or inconsistencies are identified Manager Coaching & Departmental Accountability Provide clear, objective, and actionable feedback to department managers based on audit findings and quality trendsSupport department managers in understanding quality expectations and identified areas requiring improvementAssist managers in developing practical corrective strategies within their departmentsProvide quality data that enables managers to hold their teams accountable for documentation, workflow, and performance expectationsMonitor whether departmental corrective actions result in measurable improvementEscalate recurring or unresolved deficiencies through the appropriate leadership structureMaintain appropriate boundaries between QA oversight and department management responsibilitiesDepartment managers remain responsible for the day-to-day performance, supervision,corrective action, and operational management of their teams. Quality Assurance is responsiblefor identifying, documenting, communicating, monitoring, and escalating quality concerns within its scope Training & Quality Education Identify training needs based on audit results, quality trends, payer changes, contractual requirements, and recurring deficienciesDevelop and deliver training regarding documentation standards, quality requirements, audit expectations, payer updates, and operational workflowsPartner with Learning & Development and department leadership to incorporate quality expectations into onboarding and ongoing employee trainingDevelop reference materials, job aids, audit guides, checklists, and other quality resourcesConduct calibration and educational sessions as neededEvaluate whether training interventions result in measurable improvements in quality performanceRecommend retraining or additional intervention when quality deficiencies continue following education Data Management, Analytics & Reporting Develop and maintain organization-wide quality dashboards, scorecards, reports, and tracking systemsEnsure quality data is accurate, current, actionable, and presented in a manner that supports leadership decision-makingValidate underlying QA data before presenting organizational quality results to leadershipAnalyze audit results to identify trends, patterns, recurring deficiencies, and root causesTrack performance by department, program, team, payer, audit category, and other relevant measuresProvide routine quality performance reports to the Directors of Community Health & OperationsProvide timely escalation reports when significant quality concerns are identifiedTrack the effectiveness of corrective action plans and continuous improvement initiativesPartner with Information Technology to ensure systems, templates, workflows, reports and data fields support accurate quality monitoringIdentify inconsistencies or limitations in available data and communicate them when reporting quality results Cross-Functional Collaboration & Continuous Improvement Work closely with department managers and organizational leadership to improve processes, reduce errors, and strengthen qualityParticipate in cross-departmental meetings, committees, and strategic initiatives as appropriateSupport organizational readiness for new programs, payer requirements, contractual changes, and policy updatesIdentify opportunities to standardize processes across departments when appropriateConduct root-cause analysis when systemic quality issues are identifiedDevelop recommendations based on quality data and measurable trendsPartner with Operations, Revenue Cycle, Finance, Information Technology, HumanResources, Learning & Development, and program leadership as appropriate to address cross-functional quality issuesSupport implementation and monitoring of approved process improvementsStrengthen PHG's overall culture of accountability, accuracy, quality, and service excellence New Program & Operational Readiness Participate in quality-readiness planning for new health plans, counties, programs, services, or significant operational changesReview applicable quality, documentation, service-delivery, authorization, encounter, and reporting requirements prior to implementationEnsure appropriate QA audit tools and monitoring processes are developed before or shortly following implementationPartner with department leadership and Learning & Development to identify training needs related to new requirementsConduct post-implementation monitoring to identify early quality concernsReport significant readiness gaps or implementation risks to the Directors of Community Health & Operations Key Performance Indicators (KPIs) The Quality Assurance Manager is responsible for establishing, monitoring, reporting, and improving quality performance. Key performance indicators may include: Documentation accuracy and completenessDocumentation timelinessAssessment and reassessment completion and timelinessCare plan completion and timelinessRequired signature completionWorkflow adherenceAudit completion rateAudit accuracy and consistencyQA staff productivityCorrective Action Plan completion rateTimeliness of corrective action resolutionPercentage of overdue corrective actionsRepeat deficiency rateDepartmental and program quality scoresHealth plan and county audit findingsExternal audit readinessReduction in recurring documentation deficienciesTraining effectiveness following identified quality concernsTimeliness and accuracy of QA reportingQuality improvement initiative completionSustained improvement following corrective actionsImplementation of new or revised payer requirementsTimeliness of escalation of high-risk findingsPerformance metrics and departmental targets may be modified based on organizational priorities, contractual obligations, payer requirements, program standards, and identified qualityrisks Quality Reporting Expectations The QA Manager is expected to provide the Directors of Community Health & Operations with consistent visibility into organizational quality performance. Routine reporting should include, as applicable: Overall organizational quality performanceDepartment and program quality scoresAudit completion statusDocumentation quality and timeliness trendsAssessment, reassessment, and care plan trendsOutstanding Corrective Action PlansOverdue corrective actionsRepeat findingsHigh-risk or systemic quality concernsHealth plan and county audit activity and findingsEmerging payer or contractual requirements affecting quality monitoringTraining needs identified through QA reviewsQuality improvement initiativesAreas demonstrating sustained improvementAreas requiring leadership interventionSignificant quality concerns, systemic failures, recurring deficiencies, or risks that could materially affect PHG's contractual performance, reimbursement, member services, audit performance, or organizational operations must be promptly escalated to the Directors of Community Health & Operations Leadership & Accountability Expectations The Quality Assurance Manager is expected to serve as the accountable leader for the Quality Assurance function and demonstrate consistent ownership of organizational quality monitoring. This includes: Proactively identifying quality concerns through established monitoring systemsEnsuring scheduled audits are completed accurately and timelyIdentifying trends before they become significant organizational risksMaintaining current awareness of applicable health plan and contractual quality requirementsDeveloping practical recommendations based on objective findingsEnsuring corrective actions are tracked through completionVerifying that corrective actions result in sustained improvementProviding leadership with accurate and timely quality informationMaintaining appropriate documentation supporting QA findingsHolding QA personnel accountable for assigned responsibilities and performance expectationsMaintaining appropriate independence and objectivity when conducting auditsEscalating significant concerns without unnecessary delayThe QA Manager is not expected to assume responsibility for managing another department's employees or day-to-day operations. Department managers remain responsible for the performance and operational management of their teamsThe QA Manager is responsible for identifying, documenting, communicating, tracking, validating, and escalating quality concerns through the appropriate leadership structure Compensation & Benefits Salary Range: $78,000.00 - $82,000.00 annuallyCompensation is commensurate with experience, certifications, qualifications, and demonstrated quality assurance, healthcare, and operational expertise Time Off & Leave 160 Hours of Paid Time Off (PTO)12 Paid Holidays, including Birthday HolidayOne Floating Holiday after one year of employmentFour (4) Paid Volunteer Hours per MonthBereavement Leave, including Pet Bereavement Leave Health & Wellness 90% Employer-Paid Employee-Only Medical CoverageDental and Vision InsuranceFlexible Spending Account (FSA)Short-Term Disability, Long-Term Disability, and AD&D CoverageEmployee Assistance Program (EAP)Financial & Professional Growth401(k) with Company MatchMonthly StipendProfessional Development OpportunitiesCareer Advancement and Internal Growth Opportunities Culture & Employee Experience Hybrid Work EnvironmentQuarterly In-Person Team and Company EventsEmployee Discount Programs through Great Work Perks and Perks at WorkMission-Driven Culture Focused on Compassion, Innovation, Accountability, Collaboration, and Growth Benefit eligibility, waiting periods, employee contributions, and plan terms are governed by the applicable plan documents and may be modified in accordance with applicable law and company policy Required Qualifications Bachelor's degree in Healthcare Administration, Public Health, Business Administration, Social Services, or a related fieldMinimum four (4) years of progressive experience in quality assurance, auditing,healthcare operations, managed care, or a related healthcare or human services environmentMinimum two (2) years of leadership, supervisory, or quality team oversight experienceDemonstrated experience conducting audits and evaluating documentation, workflows, and operational qualityStrong understanding of healthcare quality assurance principles, documentation standards, quality monitoring, and process improvement methodologiesExperience developing corrective action plans and monitoring improvement through resolutionStrong analytical skills with the ability to identify patterns, conduct root-cause analysis, and translate findings into actionable recommendationsDemonstrated ability to develop and monitor quality metrics, dashboards, and performance reportsStrong leadership, coaching, communication, and interpersonal skillsAbility to provide objective feedback and influence leaders and staff across multiple departmentsExcellent written and verbal communication skillsStrong organizational skills and attention to detailAbility to manage multiple priorities, deadlines, audits, and improvement initiatives simultaneouslyProficiency with Microsoft Office Suite, reporting tools, workflow systems, and electronic documentation platforms Preferred Qualifications Experience with Medi-Cal and California managed care organizationsExperience with CalAIM programs, including Enhanced Care Management and Community SupportsExperience with Community Health Worker, Behavioral Health, care management, or other community-based healthcare programsExperience preparing for or participating in health plan, county, payer, or contractual auditsExperience developing organization-wide quality programs and standardized audit methodologiesExperience with electronic health records, healthcare data systems, and quality reporting platformsExperience interpreting payer requirements and translating them into operational audit standardsExperience working in a rapidly growing or multi-program healthcare organizationQuality, healthcare, auditing, or process-improvement certification preferred Work Environment Hybrid, California-based positionFull-time schedule, Monday through Friday, 8:30 AM-5:00 PM, with flexibility based on organizational needsIn-person attendance may be required for meetings, trainings, audits, program activities, or organizational eventsPeriodic travel to PHG offices, program locations, community sites, or other locations may be required based on operational or audit needsFast-paced and highly accountable environment requiring strong organization, analytical thinking, independent judgment, objectivity, and proactive communicationMust maintain confidentiality and appropriately safeguard member information, employee information, quality records, payer information, and protected health informationMust work collaboratively across departments while maintaining the independence and objectivity necessary for the Quality Assurance function Performance Expectations The Quality Assurance Manager is expected to demonstrate measurable and sustained improvement in organizational quality performance, including documentation accuracy, documentation timeliness, audit performance, corrective action completion, reduction of recurring deficiencies, health plan and county audit readiness, quality reporting, and departmental accountabilityThe QA Manager is expected to independently identify quality concerns within the scope of the position, develop appropriate recommendations, initiate quality improvement activities, monitor corrective actions, and follow identified concerns through resolutionThe QA Manager must maintain consistent visibility into organizational quality trends and proactively communicate significant concerns, emerging risks, and unresolved deficiencies to the Directors of Community Health & Operations Equal Opportunity Employer Pacific Health Group is an Equal Opportunity Employer. Qualified applicants will receive consideration for employment without regard to any characteristic protected under applicable federal, state, or local law.