Quality Manager

🔥 16 hours ago

🤠 Texas – Remote

🤠 Texas – Remote

💵 $100k - $125k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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WNS

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1996

⚖️ Legal

📦 Logistics

📣 Marketing

Legal • Logistics • Marketing

WNS is a global business process management company that operates across 13 countries with over 66 delivery centers and employs more than 62,000 people. The organization is committed to inclusivity and diversity, fostering a unique culture of co-creation and continuous learning. WNS offers various career opportunities across the Asia Pacific, Europe, Africa, and the Americas, and prides itself on its transparent and merit-based recruitment process. As a leader in its field, WNS focuses on nurturing future leaders and decision-makers while maintaining a strong emphasis on social responsibility through initiatives like the WNS Cares Foundation.

📋 Description

• Lead the Quality Management Program, including annual 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 • Oversee utilization management workflows, policies, and operational processes for quality 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 • 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, reporting, and recommendations to leadership • Maintain Quality Management Program documentation, work plans, evaluations, committee records, quality improvement projects, and required reports • Analyze and present quality, compliance, accreditation, complaint, utilization management, and audit data • Oversee complaint investigations, trend analysis, reporting, and corrective actions • Oversee fraud, waste, and abuse reporting activities and documentation • Oversee 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 applicable regulations, accreditation standards, company policies, privacy requirements, and professional standards • Provide exceptional service to internal and external stakeholders and perform other assigned duties

🎯 Requirements

• 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

🏖️ Benefits

• Performance-based bonuses, incentive pay, or commissions may be available • 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 • Equal Opportunity Employer • Reasonable accommodations for disabilities and sincerely held religious beliefs

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