Manager- Quality & Acc.

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 bachelors 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  $100000 to $125000 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 candidates 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

Equal Opportunity Employer Statement

WNS is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.

All qualified applicants will receive consideration for employment without regard to race color religion sex (including pregnancy childbirth or related medical conditions) sexual orientation gender identity or expression national origin age disability genetic information veteran status or any other status protected under federal state or local law.

We also provide reasonable accommodations to individuals with disabilities and for sincerely held religious beliefs in all aspects of employment including the application process.

How to Apply
Please submit your application including a resume and optional cover letter through our careers page or email to

Remote Work :

Yes

Employment Type :

Full-time