Job Description
MAJOR RESPONSIBILITIES
Support the business in achieving the goals of the Quality Department through the following responsibilities:
• Leads the Quality Management Program, including annual program evaluation, quality improvement initiatives, KPI development, performance monitoring, and implementation of continuous process improvements.
• Identifies compliance, accreditation, contractual, and operational risks; conducts root cause analyses; develops corrective action plans; monitors effectiveness of interventions; and escalates significant issues as appropriate.
• Develops, implements, and oversees quality audit programs for clinical and physician review activities, including IRR audits, adverse determination reviews, and data integrity audits, ensuring alignment with contractual, regulatory, and accreditation requirements.
• Ensures audit findings are accurate, consistent, defensible, and supported by standardized methodologies, appropriate sampling techniques, and regulatory requirements.
• Maintains expertise in utilization management workflows, policies, and operational processes to ensure meaningful oversight and auditing activities.
• Partners with operations, clinical leadership, compliance, education, IT, and other stakeholders to resolve deficiencies, improve processes, and sustain corrective actions.
• Maintains readiness for accreditation surveys, client audits, and regulatory reviews by monitoring changing requirements, updating policies and audit criteria, maintaining evidence repositories, and coordinating survey activities.
• Oversees URAC and NCQA accreditation activities, including standards interpretation, gap assessments, survey preparation, application management, and response coordination.
• Leads preparation for external audits, surveys, and delegated oversight reviews conducted by clients, regulators, and accrediting organizations.
• Leads Quality Management and Compliance Committees and provides governance, oversight, reporting, and recommendations to organizational leadership.
• Maintains Quality Management Program documentation, including program descriptions, work plans, annual evaluations, committee records, quality improvement projects, and required reports.
• Analyzes and presents quality, compliance, accreditation, complaint, utilization management, and audit data to leadership, committees, clients, and external stakeholders.
• Oversees complaint investigations, trend analysis, reporting, and corrective actions in accordance with contractual, accreditation, and regulatory requirements.
• Oversees fraud, waste, and abuse reporting activities and ensures appropriate reporting and documentation in accordance with company policies and contractual requirements.
• Oversees regulatory and accreditation-required education tracking, exclusion monitoring, clinician credentialing, licensure verification, and credentialing record maintenance.
• Provides leadership, coaching, performance management, workload balancing, succession planning, and professional development for Quality team members.
• Ensures compliance with all applicable federal and state regulations, accreditation standards, company policies, privacy requirements, and professional standards.
• Provides exceptional service to internal and external stakeholders and performs other duties as assigned.
Qualifications
• Graduate of an accredited nursing program; active, unrestricted RN license required. BSN, MSN, or other bachelor's degree preferred.
• 5+ years of utilization management experience in a health plan, UM vendor, or delegated UM organization, including prior authorization.
• 3+ years of quality, audit, compliance, accreditation, or quality management experience, including audit programs, KPI reporting, and corrective action planning.
• 2+ years of progressive leadership experience in a managed care environment with responsibility for staff performance and team outcomes.
• Demonstrated success developing KPIs, conducting root cause analyses, and driving measurable performance improvement.
• Working knowledge of URAC and/or NCQA accreditation standards and quality management program requirements; participation in accreditation surveys or delegation audits preferred.
• Knowledge of Medicare, Medicaid, and commercial utilization management regulations, including CMS and state utilization review requirements.
• Prior quality management experience within a health plan or delegated utilization management organization strongly preferred.
• CPHQ certification preferred; Lean Six Sigma or other process improvement training is a plus.
• Experience leading quality, productivity, and performance improvement initiatives.
• Strong leadership, facilitation, communication, critical thinking, and organizational skills.
• Ability to thrive in a fast-paced, evolving environment and collaborate effectively across teams.
ENVIRONMENT AND PHYSICAL DEMANDS
• HIPAA-compliant remote location with reliable high-speed internet.
• Ability to use the telephone, sit, enter data and view a PC screen for up to 8 hours.
• Ability to prioritize in a multi-task environment.
Additional Information
Compensation Disclosure
The base salary range for this position is $100,000 to $125,000 annually. This represents the base pay range that we reasonably expect to offer for this position.
Final compensation will be determined based on a variety of factors, including but not limited to the candidate's experience, education, skillset, and location.
• Geographic location
• Overall professional experience
• Directly relevant experience
• Education and certifications
• Industry knowledge and expertise
• Skills and competencies
In addition to base pay, this role may be eligible for performance-based bonuses, incentive pay, or commissions, which are not included in the listed base salary range.
WNS complies with all applicable federal, state, and local pay transparency laws, including those in California, Colorado, New York, Washington, and Illinois.
Note: For complete compensation information, please refer to the job posting on our official careers page.
Benefits Overview
Our benefits package includes (but is not limited to):
- Medical, dental, and vision insurance
- Paid time off (PTO), holidays, and sick leave
- 401(k) with company match or other retirement plan
- Life and AD&D Insurance
- Employee Assistance Program
How to Apply
Please submit your application, including a resume and optional cover letter, through our careers page or email to [redacted].
