Senior Clinical Quality Program Manager

4 days ago

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WellSky

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WellSky is a leading healthcare technology company dedicated to improving healthcare and community care outcomes worldwide. By offering comprehensive software solutions and analytics, WellSky enables healthcare providers, payers, and community organizations to collaborate and enhance care quality and accessibility. Their focus spans intelligent care management, connected care networks, and transformative analytics, aiming to create more efficient, inclusive, and sustainable healthcare systems. WellSky addresses social determinants of health and emphasizes patient and family engagement, supporting care in various settings including home, long-term, and acute care.

1001 - 5000 employees

Founded 1980

⚕️ Healthcare Insurance

☁️ SaaS

🤖 Artificial Intelligence

💰 Private Equity Round on 2020-07

📋 Description

• The Clinical Quality Program Manager adheres to WellSky's Utilization Management Program Description and Quality Improvement Program requirements and serves as a clinical subject matter expert on relevant regulatory state and federal requirements under CMS, NCQA, and other governing bodies. • The Manager drives adherence to the Utilization Management Program Description and Quality Improvement Program requirements by organizing, analyzing, and presenting data so that information can be used to consistently apply clinical guidance across the organization and set best practice standards across various lines of business managing post-acute health care settings. • Coordinates accreditation and regulatory requirement activities related to performance measurement and outcomes on behalf of the organization. • Stay up to date on relevant state and federal regulations, CMS guidelines, NCQA requirements, and other governing bodies' standards. • Ensure that the organization adheres to Utilization Management Program Description and Quality Improvement Program requirements. • Responsible for developing and overseeing WellSky's UM internal audit protocol. • Develops performance improvement plans and oversees clinical quality improvement activities/projects. • Generate and perform data validation checks on monthly/quarterly/ad hoc universe reports. • Organize, analyze, and present data to identify trends, gaps, and areas for improvement. • Develop and maintain reporting mechanisms to monitor clinical quality and performance. • Participate in, prepare for, and support regulatory accreditation and contractual audits. • Initiate, investigate, present, drive, and track remediation of internal and external audits. • Maintain accurate and organized records related to clinical quality and compliance. • Ensure that the organization's policies and procedures align with regulatory requirements. • Responsible for ongoing monitoring and remediation of post-hire primary source verification of clinical licenses, certifications, and board actions.

🎯 Requirements

• Registered Nurse, Occupational Therapist, or Physical Therapist with a Bachelor’s degree in a related field or a combination of education and experience including pertinent clinical experience with an understanding of CMS standards and guidelines • At least 8 years of relevant experience in healthcare quality management, utilization management, or related roles. • Ability to manage multiple competing priorities and tasks. • Excellent written, oral, and interpersonal communication skills • Excellent analytical and data interpretation skills. • Utilization management, utilization review, or case management experience in a health care setting is highly preferred. • Ability to manipulate and sort data for analytics and reporting. • Demonstrated ability to manage external vendors and clients. • Experience with CMS and/or NCQA audits is highly preferred.

🏖️ Benefits

• 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