Manager – Quality & Acc.

🕒 Outubro 27

🤠 Texas – Remoto

🤠 Texas – Remote

💵 $100.000 - $125.000 / ano

⏰ Tempo Integral

🟡 Pleno

🟠 Sênior

👔 Gerente

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WNS

SiteLinkedInTodas as Vagas

10.000+ funcionários

Fundada em 1996

⚖️ Jurídico

📦 Logística

📣 Marketing

Legal • Logistics • Marketing

WNS é uma empresa global de Business Process Management (BPM) que atua em 13 países, com mais de 66 centros de entrega, e emprega mais de 62 mil pessoas. A organização tem compromisso com a inclusão e a diversidade, promovendo uma cultura única de cocriação e aprendizado contínuo. A WNS oferece diversas oportunidades de carreira na Ásia-Pacífico, Europa, África e Américas e se orgulha de um processo de recrutamento transparente e baseado em mérito. Como líder em seu segmento, a WNS foca no desenvolvimento de futuros líderes e tomadores de decisão, mantendo forte ênfase em responsabilidade social por meio de iniciativas como a WNS Cares Foundation.

Descrição

• Lead the Quality Management Program, including annual program evaluation, quality improvement initiatives, KPI development, performance monitoring, and continuous process improvements • Identify compliance, accreditation, contractual, and operational risks; conduct root cause analyses; develop corrective action plans; monitor intervention effectiveness; and escalate significant issues • Develop, implement, and oversee quality audit programs for clinical and physician review activities, including IRR audits, adverse determination reviews, and data integrity audits • Ensure audit findings are accurate, consistent, defensible, and supported by standardized methodologies, sampling techniques, and regulatory requirements • Maintain expertise in utilization management workflows, policies, and operational processes for oversight and auditing • Partner with operations, clinical leadership, compliance, education, IT, and other stakeholders to resolve deficiencies and sustain corrective actions • Maintain readiness for accreditation surveys, client audits, and regulatory reviews by monitoring requirements, updating policies and audit criteria, maintaining evidence repositories, and coordinating survey activities • Oversee URAC and NCQA accreditation activities, including standards interpretation, gap assessments, survey preparation, application management, and response coordination • Lead preparation for external audits, surveys, and delegated oversight reviews • Lead Quality Management and Compliance Committees and provide governance, oversight, reporting, and recommendations to organizational leadership • Maintain Quality Management Program documentation, including program descriptions, work plans, annual evaluations, committee records, quality improvement projects, and required reports • Analyze and present quality, compliance, accreditation, complaint, utilization management, and audit data to leadership, committees, clients, and external stakeholders • Oversee complaint investigations, trend analysis, reporting, and corrective actions • Oversee fraud, waste, and abuse reporting activities and related documentation • Oversee regulatory and accreditation-required education tracking, exclusion monitoring, clinician credentialing, licensure verification, and credentialing record maintenance • Provide leadership, coaching, performance management, workload balancing, succession planning, and professional development for Quality team members • Ensure compliance with federal and state regulations, accreditation standards, company policies, privacy requirements, and professional standards • Provide exceptional service to internal and external stakeholders and perform other assigned duties

🎯 Requisitos

• Graduate of an accredited nursing program • Active, unrestricted RN license required • 5+ years of utilization management experience in a health plan, UM vendor, or delegated UM organization, including prior authorization • 3+ years of quality, audit, compliance, accreditation, or quality management experience, including audit programs, KPI reporting, and corrective action planning • 2+ years of progressive leadership experience in a managed care environment with responsibility for staff performance and team outcomes • Demonstrated success developing KPIs, conducting root cause analyses, and driving measurable performance improvement • Working knowledge of URAC and/or NCQA accreditation standards and quality management program requirements • Knowledge of Medicare, Medicaid, and commercial utilization management regulations, including CMS and state utilization review requirements • Experience leading quality, productivity, and performance improvement initiatives • Strong leadership, facilitation, communication, critical thinking, and organizational skills • Ability to thrive in a fast-paced, evolving environment and collaborate effectively across teams • HIPAA-compliant remote location with reliable high-speed internet • Ability to use the telephone, sit, enter data, and view a PC screen for up to 8 hours • Ability to prioritize in a multi-task environment • BSN, MSN, or other bachelor's degree preferred • Participation in accreditation surveys or delegation audits preferred • Prior quality management experience within a health plan or delegated utilization management organization strongly preferred • CPHQ certification preferred; Lean Six Sigma or other process improvement training is a plus

🏖️ Benefícios

• Medical, dental, and vision insurance • Paid time off (PTO), holidays, and sick leave • 401(k) with company match or other retirement plan • Life and AD&D Insurance • Employee Assistance Program • Performance-based bonuses, incentive pay, or commissions may be available • Reasonable accommodations for individuals with disabilities and sincerely held religious beliefs

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