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Job Description:

JR206997 Clinical Quality Program Manager

Responsible for serving as a liaison with and overseeing the quality improvement activities/projects/programs for one or more states within a major line of business. This position will primarily support Accreditation readiness activities and serve as a key quality partner in ensuring ongoing compliance with Accreditation standards, with a strong emphasis on NCQA Accreditation requirements, regulatory expectations, and continuous quality improvement.

Location: Hybrid 1: This role requires associates to be in-office 1 day per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law.

How will you make an impact:

• Leads state level quality strategy meetings, develops a quality plan, and ensures integration of quality into the overall business process.
• Serves as a subject matter expert and quality lead for Accreditation readiness efforts, including interpretation, implementation, monitoring, and documentation of NCQA Accreditation standards and requirements.
• Partners with business leaders and cross-functional teams to establish, track, and achieve Accreditation-related milestones, deliverables, and readiness activities.
• Works with the clinical intervention team to design studies to identify barriers to medical interventions.
• Ensures that study methodology is sound and appropriate reporting is in place.
• Develops performance improvement plans and oversees the clinical quality improvement activities/projects to improve the quality of care for members.
• Assures compliance with corporate QI work plans.
• Assures that all QI activities are relevant to the needs of targeted population.
• Maintains effective documentation of research programs to meet regulatory and Accreditation Standards.
• Coordinates and organizes Accreditation work plans, evidence collection, gap assessments, and readiness reviews to support successful Accreditation submissions and surveys.
• Provides oversight to assure accurate and complete quantitative analysis of clinical data and presentation of data analysis results.
• Participates in and provides input to the development of new product designs for major line of business.
• Oversees the implementation of new initiatives.
• Collaborates effectively with operational, clinical, compliance, accreditation, and business partners to drive process improvements, strengthen quality outcomes, and support Accreditation performance goals.
• Leads interactions with regulators or oversight entities.
• Oversees quality improvement activities for the largest, most complex state programs.
• Identifies opportunities to improve processes, workflows, documentation practices, and operational controls to enhance organizational readiness and maintain compliance with Accreditation standards.
• Develops and delivers education, guidance, and consultation to stakeholders regarding Accreditation requirements, quality standards, and readiness expectations.

Minimum requirements:

• Requires a BS in health administration, nursing, or a related clinical field; 4 years of health care quality or data analysis experience; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities, and Experiences:

• Strong knowledge of NCQA Accreditation standards, accreditation survey processes, quality management principles, and healthcare regulatory requirements is strongly preferred.
• Candidates should possess exceptional organizational, project management, and communication skills, with demonstrated ability to manage multiple priorities, coordinate across diverse stakeholder groups, and drive complex initiatives to successful completion.
• Experience leading cross-functional teams and facilitating process improvement efforts in support of Accreditation readiness is highly desirable.
• Current unrestricted license, certification in applicable field (i.e., CPHQ) and/or an MS in the health field (i.e., Nursing) is preferred.

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