Quality & Accreditation Leader - UM & Compliance

Wns; Houston (TX); Remote; USD 100,000 - 125,000; Full time

Benefits offered by this job

Medical, dental, and vision insurance

PTO, holidays, and sick leave

401(k) with company match

Life and AD&D Insurance

Employee Assistance Program

Job summary

WNS, part of Capgemini, is a leading agentic AI-powered operations and transformation partner serving 700+ clients across industries in the US. This role drives the Quality Management Program, accreditation activities, and regulatory compliance within a dynamic managed care environment in Houston, TX, with HIPAA-compliant remote setup.

The candidate will lead KPI development, audits, corrective actions, and governance, collaborating across operations, clinical leadership, compliance, and IT to

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.
• 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.

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.

Skills

Leadership

Communication

Critical thinking

Organizational skills

Facilitation

Education

RN license

BSN/MSN preferred

Job description

WNS, part of Capgemini, is a leading agentic AI-powered operations and transformation partner serving 700+ clients across industries in the US. This role drives the Quality Management Program, accreditation activities, and regulatory compliance within a dynamic managed care environment in Houston, TX, with HIPAA-compliant remote setup.

The candidate will lead KPI development, audits, corrective actions, and governance, collaborating across operations, clinical leadership, compliance, and IT to