Manager, Clinical Quality

Healthcare,Medical Management,Business Process ","description":"

Manager, Clinical Quality

Manager II BPM

Who We Are:

UST HealthProof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations. Our BPaaS solutions manage complex admin tasks, allowing our customers to prioritize memberswell-being. With our commitment to simplicity, honesty, and leadership, we navigate challenges with our customers to achieve affordable health care for all.

We have a strong global presence and a dedicated workforce of over 4000 people spread across the world.

Our brand is built on the strong foundation of simplicity, integrity, people-centricity, and leadership. We stay inspired in our goal to unburden healthcare and ensure it reaches all, equitably and effectively.

You Are:

UST HealthProof is searching for a highly motivated Manager, Clinical Quality to join our team. As a Manager, Clinical Quality, you are responsible for management and oversight of activities related to quality assurance and monitoring of clinical UM and A&G staff on behalf of health plan customers for Utilization Management, Appeals & Disputes, Quality Improvement and other programs requiring clinical quality oversight.

The Opportunity:

Management and oversight of a quality team conducting quality assurance activities across multiple locations, UM training, and UM regulatory reporting.

Oversight of key metrics, including quality, productivity, and compliance

Responsible for the successful execution of the Quality Improvement Program in accordance with CMS requirements including review and submission of Quality of Care & Quality of Service grievances.

Support all related compliance audits on behalf of health management programs.

Plans, organizes, and directs activities of Clinical Quality, including, but not limited to, planning, training, motivation, staff development, staff selection, and communication.

Ensures subject matter expertise and support related to clinical quality management inquiries within requests for proposals and customer presentations.

Maintains and promotes quality relationships with internal and external customers.

Compiles and analyzes data and prepares activity related reports, staffing needs, inventories and monitors workflows within the clinical quality unit.

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

What You Need:

Bachelordegree in nursing is required. Masterdegree in nursing or related field and\/or CPHQ is preferred.

Ten years of experience with progressive responsibility in healthcare administration, clinical quality or a health plan with demonstrated technical knowledge that provides the necessary knowledge, skills, and abilities required.

Five years management experience in Health Management required with a focus on Quality and Utilization Management.

Skills & Competencies:

Ability\/willingness to develop, recommend and execute solutions to ad hoc issues and challenges that may arise with a process efficiency mindset.

Strong knowledge of clinical and quality improvement processes and concepts.

Subject matter expertise in Medicare Advantage and Utilization Management

Strong knowledge of CMS regulations for Medicare Advantage, Utilization Management, and\/or Appeals & Disputes.

Knowledge of CMS regulatory reporting for Utilization Management

Ability and willingness to delegate, guide and oversee work of team.

Excellent analytical, organizational, planning, verbal, and written communication skills required.

Must be self-motivated, results-oriented and can work well under pressure with multiple clients and multiple systems

Ability to effectively present information and respond to questions from internal and external contacts at all levels of the organization.

Proficient in current industry standard PC applications and systems and health management systems.

Extensive knowledge of operations and ability to lead a team to meet industry standard SLAand metrics.

Must demonstrate leadership ability and team building skills to effectively supervise professional and non-professional staff and interact with all levels of management.

Ability to effectively exchange information, verbal or written, by sharing ideas, reporting facts and other information, responding to questions, and employing active listening techniques.

Ability to establish workflows, manage multiple projects, and meet necessary deadlines.

Ability to maintain confidentiality.

Ability to manage both an onshore and offshore team efficiently and effectively across multiple locations and time zones.

Compensation can differ depending on factors including but not limited to the specific office location, role, skill set, education, and level of experience. UST HealthProof provides a reasonable range of compensation for roles that may be hired in various U.S. markets as set forth below.

Role Location: Remote

Compensation Range:$90,000-$105,000

Benefits

Full-time, regular employees accrue up to 16 days of paid vacation per year, receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year), 10 paid holidays, and are eligible for paid bereavement leave. They are eligible to participate in the Company401(k) Retirement Plan with employer matching. They and their dependents residing in the US are eligible for medical, dental, and vision insurance, as well as the following Company-paid benefits: basic life insurance, accidental death and disability insurance, and short- and long-term disability benefits. Regular employees may purchase additional voluntary short-term disability benefits, and participate in a Health Savings Account (HSA) as well as a Flexible Spending Account (FSA) for healthcare, dependent child care, and\/or commuting expenses. Certain regular employees may have the potential for quarterly incentive-based bonuses and or commissions depending on role. Benefits offerings vary in Puerto Rico.

Part-time employees receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year) and are eligible to participate in the Company401(k) Retirement Plan with employer matching.

Full-time temporary employees receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year) and are eligible to participate in the Company401(k) program with employer matching. They and their dependents residing in the US are eligible for medical, dental, and vision insurance.

Part-time temporary employees receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year).

All US employees who work in a state or locality with more generous paid sick leave benefits than specified here will receive the benefit of those sick leave laws.

What We Believe

At UST HealthProof, we envision a bold future for American healthcare. Our values are the bedrock beliefs our organization holds dear. They not only define what our brand stands for but also serve as a compass guiding every action and decision.

Guiding Principles

These principles illuminate the path of howwe operate. They detail actions and behaviors we much embody to honor our values and achieve our goals.

Simplicity

Simplifying complexity underlines everything we dothis approach is what makes us unique. We come with an open mind and straightforward approach, cutting our way to the core with measurable and actionable insights.

Integrity

Integrity is our currency to build relationships. We believe in being open and honest. It is only natural when we have nothing to hide. It demonstrates that we are here to do the right thing, no matter who is watching.

People-Centricity

Everything that we do reflects our deep bonds with peers and customers. These arent mere transactions, but transformational ties. They shape our culture and decisions, affirming that our true value lies in the lives we touch and impact.

Leadership

Taking ownership is about taking initiative, being in-charge and driving things to completion. Ita brave choice to ownall aspects of our work, ensuring we take full responsibility for everything we handle.

Mission

A future possible only when health plans are free from administrative burdens so they can truly focus on what matters more their memberswell-being.

Equal Employment Opportunity Statement

UST HealthProof is an Equal Opportunity Employer.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other applicable characteristics protected by law. We will consider qualified applicants with arrest or conviction records in accordance with state and local laws and fair chanceordinances.

UST HealthProof reserves the right to periodically redefine your roles and responsibilities based on the requirements of the organization and\/or your performance.

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