Manager, Clinical Quality

HealthEdge is on a mission to drive a digital transformation in healthcare. We’re connecting health plans, providers, and patients with end-to-end digital technology solutions to support new business models, reduce administrative costs and improve health outcomes. Our growing portfolio of products (HealthRules® Payer, HealthEdge Source™, HealthEdge® Provider Data Management, GuidingCare®, and Wellframe™) provides talented and passionate professionals with opportunities to lead change and make a lasting, global impact in healthcare. Driving our mission are 2,000+ professionals worldwide. Together, we are committed to innovating a world where healthcare can focus on people.

The Manager, Clinical Quality is responsible for management and oversight of activities related to quality assurance and monitoring of clinical UM and A&G staff on behalf of health plan customers for Utilization Management, Appeals & Disputes, Quality Improvement and other programs requiring clinical quality oversight. This position provides effective and efficient solutions to complex business problems. Responsibilities include maintaining effective relationships within and across teams, key vendors, and clients to ensure that the clinical quality issues and needs of health plan customers are represented and prioritized in all clinical programs. This role is also responsible for strategizing, innovating, analyzing, planning, organizing, reporting, collaboration and other functions that are required to maintain and operate the clinical quality team.

Management and oversight of a quality team conducting quality assurance activities across multiple locations, UM training, and UM regulatory reporting. Oversight of key metrics, including quality, productivity, and compliance Responsible for the successful execution of the Quality Improvement Program in accordance with CMS requirements including review and submission of Quality of Care & Quality of Service grievances. Support all related compliance audits on behalf of health management programs. Plans, organizes, and directs activities of Clinical Quality, including, but not limited to, planning, training, motivation, staff development, staff selection, and communication. Ensures subject matter expertise and support related to clinical quality management inquiries within requests for proposals and customer presentations. Maintains and promotes quality relationships with internal and external customers. Compiles and analyzes data and prepares activity related reports, staffing needs, inventories and monitors workflows within the clinical quality unit. Leads and participates in workgroups to complete special assignments/projects. Resolves high priority inquiries– including issues of non-compliance with related vendors or programs. Recommends processes to control expenditures and promotes efficient use of resources. Responsible for balancing workload to optimize the effectiveness of the department. DIRECTION EXERCISED: Directly supervises staff in accordance with company policies and applicable Federal and State Laws. Responsibilities include, but are not limited to, effectively interviewing, hiring, terminating, and training employees; planning, assigning, and directing work; appraising performance; rewarding and counseling employees; addressing complaints and resolving problems; supporting and encouraging the engagement process.