Sr. Manager, Quality Assurance and Compliance

The Job

The Senior Manager of Quality Assurance and Compliance is responsible for establishing and maturing an effective quality and compliance program across Operational areas. This includes evaluating operational controls, guidelines, tools and processes for monitoring, reviewing audits meet accuracy, timeless and contractual obligations, and enhancing operational processes.

This role serves as the second line of defense for the organization ensuring the organization is adhering to regulations and maintaining high quality standards in operations. This function plays a vital role in ensuring the accuracy, timeliness, and efficiency of operations processing and maintaining compliance with regulatory and operational requirements.

Responsibilities

• Develop and implement a quality assurance program
• Review audits to meet accuracy, timeliness, and contractual obligations
• Enhance operational processes
• Partner with Operations leadership to design and develop an effective Quality Assurance and Compliance program
• Gaining alignment on methodology, audit approach, KPIs, standards and issue resolution process
• Manage quality and Compliance reporting
• Collaborate with operational partners to align workflows, address barriers to performance, and implement initiatives to enhance operations and member satisfaction
• Monitor and communicate performance trends, track and analyze key performance indicators (KPIs)
• Share actionable insights and recommendations with senior leadership to inform strategic planning and resource allocation
• Establish effective governance framework to include Audit the Auditor mechanism to achieve organizational goals related to quality and compliance
• Lead a team of quality assurance and compliance professionals, mentoring, fostering positive team culture, promoting leadership growth, encouraging innovation, and continuous learning to achieve team or individual goals
• Identify trends and areas of opportunity for process improvements and additional training
• Work closely with operations leadership to review findings, develop action plans and remediate issues
• Partner with operational leadership to review findings, develop corrective action plans, and remediate identified issues to the root cause ensuring a closed loop process
• Monitor industry trends, regulatory changes and current events to ensure team remains informed and adapts to evolving policies and procedures
• Supervise/Manage Others (i.e. hires, performance reviews, corrective action, etc.)

Qualifications

• Bachelor’s Degree required. Graduate or Advanced Degree or equivalent experience preferred.
• Audit Certification preferred.
• 5 years of related experience QA and compliance operations experience with Medicare and Medicaid.
• 3+ years’ management experience in healthcare environment, preferably Medicare Advantage.
• 8+ years of progressive experience in healthcare or health plan operations.
• Experience managing Quality Assurance and/or Operations Audit team.
• Experience working with AI or other machine learning tools to assist with streamlining QA processes.
• Deep experience in operational areas such as claims, configuration, provider data, benefits, enrollment, appeals and grievances.
• Proven success leading quality and compliance in a matrixed environment.
• Strong working knowledge of CMS and state regulations and operational implications.
• Leadership - Skilled to develop others.
• Problem Solving - Make critical decisions, often involving high-level risk assessment and the ability to adapt to changing circumstances.
• Strategic Mindset - Formulates strategy and maps steps to achieve strategic goals.
• Business Insight - In-depth understanding of the business.
• Strong verbal and written communication skills and interpersonal skills.
• Strong analytical and critical thinking skills.
• Detail oriented, organized and strong time management skills.