Quality & Accreditation Manager

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

Benefits offered by this job

Medical, dental, vision insurance

PTO, holidays, and sick leave

401(k) with company match

Life and AD&D Insurance

Employee Assistance Program

Job summary

WNS, a Capgemini subsidiary, seeks a seasoned Quality Management and Compliance leader to drive the Quality Management Program, oversee accreditation activities, and coordinate audits across regulatory and client requirements.

Ideal candidate has RN licensure, 5+ years in utilization management, and 2+ years in health-plan leadership with KPI-driven improvements; familiarity with URAC/NCQA, CMS regulations, and process improvement is preferred.

Qualifications

• RN license active and unrestricted.
• 5+ years of utilization management experience in health plan, UM vendor, or delegated UM org.
• 3+ years in quality, audit, compliance, accreditation, or quality management with KPI reporting and corrective action planning.
• 2+ years of progressive leadership in managed care with team outcomes responsibility.
• Knowledge of URAC and/or NCQA accreditation standards; surveys or audits preferred.
• CMS/state utilization review regs knowledge.
• CPHQ preferred; Lean Six Sigma or similar process improvement training is a plus.

Responsibilities

• Leads the Quality Management Program, including annual program evaluation and KPI development.
• Identifies risks, performs root cause analyses, and develops corrective action plans; escalates issues as needed.
• Oversees quality audit programs for clinical and physician review activities with IRR audits and data integrity reviews.
• Maintains readiness for accreditation surveys, client audits, and regulatory reviews; coordinates survey activities.
• Oversees URAC and NCQA accreditation activities, including standards interpretation and survey preparation.
• Leads external audits, surveys, and delegated oversight reviews conducted by clients and regulators.
• Leads Quality Management and Compliance Committees with governance and reporting to leadership.
• Maintains program documentation and analyzes data for leadership and stakeholders.

Skills

Leadership

KPIs

Root cause analysis

Communication

Regulatory compliance

Education

RN license

BSN preferred

Quality/regulatory training

Job description

WNS, a Capgemini subsidiary, seeks a seasoned Quality Management and Compliance leader to drive the Quality Management Program, oversee accreditation activities, and coordinate audits across regulatory and client requirements.

Ideal candidate has RN licensure, 5+ years in utilization management, and 2+ years in health-plan leadership with KPI-driven improvements; familiarity with URAC/NCQA, CMS regulations, and process improvement is preferred.