“Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors.  A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate.”

This position is not eligible for Sponsorship.

Summary

The Manager of Clinical Quality Monitoring and Oversight is a licensed clinician responsible for managing the clinical monitoring and oversight activities of the Accreditation, Quality & Utilization Review (AQUR) department in accordance with State, Federal, client contractual, and accreditation requirements. The Manager directs the department’s retrospective case audit, delegation oversight, and inter-rater reliability programs across all lines of business and utilization management platforms and manages a multidisciplinary team of clinical and non-clinical quality staff with a Lead/Supervisor directly reporting to the position. The Manager serves as the second-level clinical authority for the department and provides continuity of departmental leadership in the absence of the Director.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Manages a multidisciplinary team performing clinical monitoring and oversight of technician, pharmacist, and physician reviewers in the PA and Appeals departments and of delegated utilization management entities, across all lines of business (Commercial, Medicare Part D, Medicaid, and Marketplace) and utilization management platforms. Oversight includes preparation of quality performance reports supporting Health Services, enterprise governance committees, and client reporting obligations. Represents the Clinical Quality team in cross-departmental, committee, and client-facing meetings and acts on behalf of the Director in the Director’s absence.

• Leads and participates in interdepartmental meetings with Leadership, providing knowledge of 

processes, audit data and trends, and accreditation and regulatory requirements.

• Leads audits of case reviews performed by prior authorization coordinators, clinical pharmacists, physician reviewers, Appeals staff, and delegated utilization management entities across all lines of business.

• Manages the delegation oversight program, including annual delegate audits, corrective action plan issuance, and monitoring of corrective actions through closure, and supports pre-delegation evaluations.
• Oversee inter-rater reliability testing for clinical and non-clinical reviewers and applies results to reviewer education, criteria clarification, and process improvement.

• Directs targeted audits of high-cost drug categories, high-risk clinical programs, and other identified risk areas, and presents findings and recommendations to leadership and governance committees.

• Performs root cause analysis that requires the entry, collecting, interpretation, and presentation of 

data internally and externally of MedImpact.

• Recommends and implements operational improvements to enhance clinical quality, efficiency, and compliance with regulatory and accreditation standards.

• Responsible for validating and reporting prior authorization metrics in alignment with performance guarantees.

• Develops, maintains, and enforces Clinical Quality policies, assists with Quality Management and Utilization Management Programs, and represents the department on relevant committees, including the Quality Improvement Committee (QIC), Utilization Management Oversight Committee (UMOC), and Clinical Performance Management Committee (cPMC).

• Analyze untimely Part D cases and assess operational defects, driving corrective actions and quality initiatives to improve outcomes.

• Develops the compliance monitoring and auditing work plan to address potential risk areas to be reviewed, including risks associated with the Part D benefit.

• Supports maintaining MedImpact’s and its Clients’ NCQA and URAC Accreditations and supports State utilization review licensure (URL) application, reporting, and audit requirements.

• Supports client oversight audits, corrective action plan responses, and delegation-related client inquiries in coordination with the Director, Account Management, and Corporate Compliance.

• Ensures monitoring methodology, sampling standards, and audit scoring criteria are defined, documented, and consistently applied across legacy and acquired operating entities and platforms.

• Hires, manages, mentors, and develops staff both directly and through a subordinate Lead/Supervisor, providing guidance on career development, performance, and personnel decisions; develops subordinate leaders and maintains a succession plan for key department roles.

• Fosters a collaborative culture within the department and across teams to achieve business objectives.

• Other duties as assigned.

Supervisory Responsibilities

Directly supervises Clinical Quality Pharmacists and other assigned clinical and non-clinical quality staff performing case audits of prior authorization coordinators, clinical pharmacists, physician reviewers, and Appeals staff, and may supervise through a Lead/Supervisor. Responsible for the overall direction, coordination, and evaluation of the unit. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems. Supports and enforces all company policies and procedures in a fair and consistent manner, taking corrective action whenever necessary. Supervises licensed and certified clinical staff and is accountable for reviewer competency, currency of professional licensure and certification, and adherence to established clinical review and audit standards.

Client Responsibilities

This is an internal and external client facing position that requires excellent customer service skills and interpersonal communication skills (listening/verbal/written). One must be able to; manage difficult or emotional client situations; Respond promptly to client needs; Solicit client feedback to improve service; Respond to requests for service and assistance from clients; Meet commitments to clients.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

Doctor of Pharmacy (Pharm.D.) or B.S. in Pharmacy, or Bachelor of Science in Nursing (BSN) or Associate Degree in Nursing, with active licensure in good standing, plus 5+ years of experience; 1 year of SME in respective area(s); and 3+ years of supervisory experience; 4 years of MedImpact experience plus an appropriate external leadership training program and internal mentorship with a seasoned leader (Dir+) that must be completed within 12 months in new position may substitute for the supervisory experience requirement only. Managed care, PBM, or health plan experience in quality management, utilization management, or accreditation is required. Working experience with NCQA and/or URAC accreditation standards and CMS Medicare Part D requirements is strongly preferred. The internal substitution pathway does not substitute for the clinical degree, licensure, or managed care experience requirements.

Computer Skills

Microsoft Office Suite (Word/Excel/Access/Outlook),Teams  and standard PDF document tools, including the ability to create, combine, annotate, and complete fillable PDF documents. Working knowledge of enterprise document management, prior authorization, appeals, and quality reporting systems is preferred.

Certificates, Licenses, Registrations

Active, unencumbered licensure as a Registered Pharmacist or Registered Nurse in the state of residence required. Willingness to obtain additional state licensure if required to support MedImpact utilization review licensure obligations. Certified Professional in Healthcare Quality (CPHQ) or equivalent quality, compliance, or managed care certification preferred.

Other Skills and Abilities

• Prior experience in clinical prior authorization and CMS Medicare Part D Coverage Determinations and Redeterminations regulations.
• Strong background in healthcare, insurance, or PBM industries, with familiarity in enterprise quality and performance improvement systems.
• Proficient in data analysis, presentation, and Microsoft Office, with solid technical and analytical skills.
• Proven leadership and progressive staff management experience, with the ability to mentor and educate team members effectively.
• Demonstrates sound judgment, discretion, and diplomatic communication skills across all organizational levels.
• Capable of independently identifying, researching, and resolving complex issues with strategic and operational insight.
• Highly organized, self-directed, and able to manage multiple priorities and deadlines in a fast-paced environment.
• Collaborative team player with strong interpersonal skills, able to work effectively with peers and leadership.
• Working knowledge of NCQA Utilization Management and/or URAC Pharmacy Benefit Management accreditation standards, and of State utilization review licensure requirements.
• Ability to apply independent clinical judgment in evaluating the appropriateness, consistency, and defensibility of coverage determinations and appeal decisions.
• Experience managing quality, audit, or oversight staff across multiple operating entities, platforms, or lines of business, including following organizational integration or acquisition.
• Experience supervising through a lead or supervisor, including delegation of work, development of subordinate leaders, and workload and capacity planning.

• Demonstrated ability to prepare and present audit findings, trend analysis, and corrective action recommendations to executive leadership, clients, regulators, and accrediting bodies.

Reasoning Ability

• Ability to define problems, collect data, establish facts, and draw valid conclusions.

Mathematical Skills

• Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.

Language Skills

• Ability to read, analyze, and interpret the most complex documents.   

• Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.

Competencies To perform the job successfully, an individual should demonstrate the following competencies:

Building Effective Teams

Decision Quality

Informing

Confronting Direct Reports

Delegation

Organizational Agility

Customer Focus

Drive for Results

Political Savvy

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit and talk or hear. The employee is regularly required to stand; walk; use hands to finger, handle, or feel and reach with hands and arms. The employee must occasionally lift and/or move up to 25 pounds. Ability to maintain clear near visual acuity at approximately 20 inches or less (i.e., “close vision”) to accurately read fine print, view computer screens, and handle small objects. Requires adequate color vision and depth perception to support safety and precision in detail-oriented tasks.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

This position may regularly be exposed to or encounter moving mechanical parts, high, precarious places, fumes, or airborne particles, toxic or caustic chemicals, outdoor weather conditions, risk of electrical shock or vibration.