Manager, Accreditation & Quality Compliance

11 - 15 years experience  •  Patient Care

Salary depends on experience
Posted on 11/10/17
Cleveland, OH
11 - 15 years experience
Patient Care
Salary depends on experience
Posted on 11/10/17


•Leads all aspects of NCQA accreditation including application, surveys and file reviews.

•Develops, monitors and maintains corporate-wide processes and projects that promote attainment of maximum points allowed for all NCQA standards. 

•Develops, implements and submits quality projects required for all federal programs.   Assures periodic reporting.

•Coaches and trains employees across the organization to assure that best practices are disseminated and incorporated across the company to support accreditation.

•Facilitates multi-disciplinary teams or work groups including Stars that collaborate cross-functionally on processes, reports and materials to meet requirements.

•Monitors ongoing changes and initiates steps to mitigate risk as needed.

•Collaborates with Chief Medical Officer and VP, Quality on agenda and presentations for quality committees.

•Reviews all written reports to assure valid methodology is followed and reports are timely and well-written, using proper grammar, punctuation, etc.

•Develops, monitors and maintains internal processes and systems to assure clinical grievances from Medicare Advantage members are handled timely, completely and accurately according to CMS regulations and policies.  Tracks inventory and assures information is in place for HPMS reporting.

•Reviews clinical grievances and assists nursing staff in facilitating resolution.  May contact members or providers as needed.

•Oversees the over-read process of HEDIS clinical data for all lines of business as conducted by nursing staff.


•Master’s Degree in Nursing, Public Health, Business or other related field preferred

•Bachelor of Science Degree in Nursing or related healthcare field required

•Minimum ten (10) years of experience in healthcare/health plan required

•Minimum (3) years of prior management experience required

•Minimum (3) years of direct applicable experience with NCQA, URAC and/or Joint Commission standards required

•Current Registered Nurse License in the State of Ohio preferred

•CPHQ  or other certification in healthcare management within 18 months of hire required

•Demonstrated experience in leading and facilitating cross-functional teams

•Demonstrated experience in developing detailed written policies and procedures

•Experience in gathering and analyzing health data and drawing conclusions

•Experience in applying scalable, disciplined and coordinated operational and technological approaches to improve health care quality and member experience and reduce costs of care

•Knowledge of HEDIS

•Continuous quality improvement/business process improvement

•Excellent demonstration of flexibility and change leadership

•Experience aligning resources to operational needs

•Excellent analytical and project management skills

•Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate course of action

•Excellent skills in organizational dynamics and ability to work with all levels of leadership including executive level and physician leadership

•Able to manage multiple priorities and meet tight deadlines

•Excellent written and verbal communication skills including presentation skills

•Proficient in Microsoft suite of products including Word, Excel and PowerPoint


Not the right job?
Join Ladders to find it.
With a free Ladders account, you can find the best jobs for you and be found by over 20,0000 recruiters.