[Hiring] Clinical Quality Program Manager @WellSky

Role Description

This job is responsible for ensuring compliance with WellSky's Utilization Management and Quality Improvement Program by serving as a clinical expert on state and federal regulations. The scope of this job includes analyzing and presenting data to establish best practices across post-acute health care settings, including LTACHs, IRFs, SNFs, and Home Health facilities.

Key Responsibilities:

• Facilitate activities related to performance measurement and outcomes, ensure the organization meets CMS, NCQA, and other regulatory standards, stay updated on relevant regulatory changes, and support their integration into practices.
• Generate and validate reports to monitor performance across health plan contracts, ensuring accuracy and alignment with requirements.
• Conduct regular audits of UM decisions, case documentation, turnaround times, and adherence to other CMS and NCQA requirements.
• Understand how the UM Program is driven by the NCQA UM standards to ensure UM Program meets all NCQA requirements for accreditation.
• Prepare and lead committee meetings on a monthly and quarterly basis, driven by NCQA requirements.
• Prepare detailed quality reports, identify and analyze trends, and present findings to leadership with actionable recommendations.
• Support implementing corrective action plans when scoring variances occur.
• Support quality improvement project initiatives.
• Prepare for regulatory, accreditation, and contractual audits, and contribute to the remediation and documentation of audit findings.
• Perform other job duties as assigned.

Qualifications

• At least 4-6 years relevant work experience
• Experience leading quality improvement projects and committee work.
• Bachelor's Degree or equivalent work experience

Requirements

• Active, unrestricted license: RN, PT, OT or SLP, with a bachelor’s degree in a related field or a combination of education and experience that includes pertinent clinical experience and advanced working knowledge of CMS standards and guidelines.
• At minimum, 1-2 years of working knowledge of NCQA UM accreditation standards.
• Must be able to prioritize, plan and handle multiple tasks and demands simultaneously, with competing deadlines.
• Excellent in manipulating and sorting data for analytics and reporting.
• Prior experience owning client compliance SLAs and ensuring success in meeting SLA requirements.

Job Expectations

• Willing to work additional or irregular hours as needed.
• Must work in accordance with applicable security policies and procedures to safeguard company and client information.
• Must be able to sit and view a computer screen for extended periods of time.
• Travel approximately 10%.

Benefits

• Excellent medical with Rx, dental, and vision benefits
• Mental Health support through EAP
• Generous paid time off, plus 13 paid holidays
• 100% vested 401(K) retirement plans
• Educational assistance up to $2500 per year