[Hiring] Associate Manager, Clinical Quality @Gainwell Technologies LLC

Role Description

We are seeking a talented individual for an Associate Manager, Clinical Quality who is responsible for supervising Quality Assurance activities for Prior Authorization reviews. The Associate Manager, Clinical Quality plays an integral role in ensuring the accuracy, consistency, timeliness, and regulatory compliance of clinical review and authorization decisions.

• Supervise the Prior Authorization quality review program, including policies, procedures, and controls supporting compliance with standards, regulations, accreditation requirements, and contracts.
• Develop and maintain quality assurance processes, audit methodologies, and performance benchmarks for medical and behavioral health Prior Authorization reviews.
• Supervise and mentor clinical quality auditors and reviewers through education, coaching, and performance feedback.
• Monitor and report quality, accuracy, timeliness, productivity, denial rationale, and interrater reliability metrics.
• Identify trends, root causes, and improvement opportunities in clinical criteria application, documentation, review consistency, and workflows.
• Analyze audit results, appeals, complaints, and regulatory findings to identify issues and recommend corrective actions.
• Prepare reports and dashboards for leadership on performance, audit outcomes, risks, and improvement initiatives.
• Ensure Prior Authorization reviews are completed accurately, consistently, and within required timeframes.
• Develop and deliver training based on audit findings, policy updates, and performance trends.
• Maintain knowledge of CMS, Medicaid, accreditation standards, clinical policies, and industry practices.
• Lead quality improvement initiatives that enhance accuracy, consistency, efficiency, and experience.
• Serve as a subject matter expert for new tools, automation, operational readiness, and escalated quality issues.
• Manage individual and team performance to meet or exceed performance standards.
• Perform other duties as assigned.

Qualifications

• Associate degree required; bachelor’s degree preferred.
• Current, unrestricted RN license required; additional utilization management, case management, or healthcare quality certification preferred.
• Working knowledge of Prior Authorization, utilization management, medical necessity review, adverse determination processes, and applicable regulatory and accreditation requirements.
• Demonstrated ability to apply evidence-based clinical criteria, health plan policies, benefit requirements, and clinical judgment consistently and accurately.
• Minimum 5 years of experience in Prior Authorization, utilization management, clinical review, or healthcare quality assurance.
• Minimum 2 years of leadership or quality assurance experience in a health plan, managed care, utilization management, or healthcare setting.
• Strong analytical, communication, coaching, and problem-solving skills, with experience using quality data to drive measurable improvement.

Requirements

• Remote- U.S.
• Up to 20% Travel
• Will accept applications until October 30, 2026.
• The pay range for this position is $71,500.00 - $102,100.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors.

Benefits

• Generous, flexible vacation policy.
• 401(k) employer match.
• Comprehensive health benefits.
• Educational assistance.
• Leadership and technical development academies to help build your skills and capabilities.