Medical Director
WellSky
Clinical Quality Program Manager
WellSky
full-time
Posted on:
Origin: • 🇺🇸 United States
Visit company websiteJob Level
Mid-LevelSenior
About the role
- 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.
- Comply with state, federal, and organizational standards by assisting in the development and enforcement of policies aligned with Utilization Management and Quality Improvement Program requirements.
- Guide the implementation of internal audit protocols in compliance with CMS regulations and NCQA standards, and contribute to the consistency of clinical documentation and decision-making processes.
- Analyze data to identify trends and areas for improvement, and execute defined projects aimed at enhancing care quality across various lines of business.
- Generate and validate reports to monitor performance and compliance across health plan contracts, ensuring accuracy and alignment with requirements.
- Prepare for regulatory, accreditation, and contractual audits, and contribute to the remediation and documentation of audit findings.
- Perform other job duties as assigned
Requirements
- Bachelor's Degree or equivalent work experience
- At least 4-6 years of relevant experience in healthcare quality management and post-acute care utilization management
- Preferred: Registered Nurse, Occupational Therapist, or Physical Therapist with a bachelor’s degree in a related field, or a combination of education and experience that includes pertinent clinical experience and an understanding of CMS standards and guidelines
- Experience with CMS and/or NCQA audits
- Ability to manage multiple competing priorities and tasks effectively
- Strong written, oral, and interpersonal communication skills
- Demonstrated ability to collaborate with external vendors and clients
- Proficiency in manipulating and sorting data for analytics and reporting
- Excellent analytical and data interpretation skills
- Experience in case management in a healthcare setting
- Applicants for U.S.-based positions must be legally authorized to work in the United States
- Certain client-facing positions may be required to comply with applicable requirements, such as immunizations and occupational health mandates
