Job Locations US-Remote

ID

2026-7741

Category

Clinical Quality

Position Type

Full-Time

Overview:

The Manager, Clinical Quality is responsible for management and oversight of activities related to quality assurance and monitoring of clinical UM and A&G staff on behalf of health plan customers for Utilization Management, Appeals & Disputes, Quality Improvement and other programs requiring clinical quality oversight. This position provides effective and efficient solutions to complex business problems. Responsibilities include maintaining effective relationships within and across teams, key vendors, and clients to ensure that the clinical quality issues and needs of health plan customers are represented and prioritized in all clinical programs. This role is also responsible for strategizing, innovating, analyzing, planning, organizing, reporting, collaboration and other functions that are required to maintain and operate the clinical quality team.

RESPONSIBILITIES:

• Management and oversight of a quality team conducting quality assurance activities across multiple locations, UM training, and UM regulatory reporting.
• Oversight of key metrics, including quality, productivity, and compliance
• Responsible for the successful execution of the Quality Improvement Program in accordance with CMS requirements including review and submission of Quality of Care & Quality of Service grievances.
• Support all related compliance audits on behalf of health management programs.
• Plans, organizes, and directs activities of Clinical Quality, including, but not limited to, planning, training, motivation, staff development, staff selection, and communication.
• Ensures subject matter expertise and support related to clinical quality management inquiries within requests for proposals and customer presentations.
• Maintains and promotes quality relationships with internal and external customers.
• Compiles and analyzes data and prepares activity related reports, staffing needs, inventories and monitors workflows within the clinical quality unit.
• Leads and participates in workgroups to complete special assignments/projects.
• Resolves high priority inquiries– including issues of non-compliance with related vendors or programs.
• Recommends processes to control expenditures and promotes efficient use of resources.
• Responsible for balancing workload to optimize the effectiveness of the department.

DIRECTION EXERCISED:

• Directly supervises staff in accordance with company policies and applicable Federal and State Laws.
• Responsibilities include, but are not limited to, effectively interviewing, hiring, terminating, and training employees; planning, assigning, and directing work; appraising performance; rewarding and counseling employees; addressing complaints and resolving problems; supporting and encouraging the engagement process.

EMPLOYMENT QUALIFICATIONS

• Bachelor’s degree in nursing is required. Master’s degree in nursing or related field and/or CPHQ is preferred. Continuous learning, as defined by the Company’s learning philosophy, is required.
• Active RN license is required.
• 10+ years experience with progressive responsibility in healthcare administration, clinical quality or a health plan with demonstrated technical knowledge that provides the necessary knowledge, skills, and abilities required.
• 5+ years management experience in Health Management required with a focus on Quality and Utilization Management.
• Ability/willingness to develop, recommend and execute solutions to ad hoc issues and challenges that may arise with a process efficiency mindset.
• Strong knowledge of clinical and quality improvement processes and concepts.
• Subject matter expertise in Medicare Advantage and Utilization Management
• Strong knowledge of CMS regulations for Medicare Advantage, Utilization Management, and/or Appeals & Disputes.
• Knowledge of CMS regulatory reporting for Utilization Management
• Ability and willingness to delegate, guide and oversee work of team.
• Excellent analytical, organizational, planning, verbal, and written communication skills required.
• Must be self-motivated, results-oriented and can work well under pressure with multiple clients and multiple systems
• Ability to effectively present information and respond to questions from internal and external contacts at all levels of the organization.
• Proficient in current industry standard PC applications and systems and health management systems.
• Extensive knowledge of operations and ability to lead a team to meet industry standard SLA’s and metrics.
• Must demonstrate leadership ability and team building skills to effectively supervise professional and non-professional staff and interact with all levels of management.
• Ability to effectively exchange information, verbal or written, by sharing ideas, reporting facts and other information, responding to questions, and employing active listening techniques.
• Ability to establish workflows, manage multiple projects, and meet necessary deadlines.
• Ability to maintain confidentiality.
• Ability to manage both an onshore and offshore team efficiently and effectively across multiple locations and time zones.

Geographic Responsibility: Remote, US

Type of Employment: Full-time, permanent

FLSA Classification (USA Only): Exempt

Work Environment: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job:

• The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

• Work across multiple time zones in a hybrid or remote work environment.

• Long periods of time sitting and/or standing in front of a computer using video technology.

• May require travel dependent on company needs.

The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required. HealthEdge reserves the right to modify, add, or remove duties and to assign other duties as necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990. Candidates may be required to go through a pre-employment criminal background check.

HealthEdge is an equal opportunity employer. We are committed to workforce diversity and actively encourage all qualified persons to seek employment with us, including, but not limited to, racial and ethnic minorities, women, veterans and persons with disabilities.

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**The annual US base salary range for this position is $95,000 to $110,000. This salary range may cover multiple career levels at HealthEdge. Final compensation will be determined during the interview process and is based on a combination of factors including, but not limited to, your skills, experience, qualifications and education.

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