Remote Associate Manager, Clinical Quality - PA

Gainwell Technologies; Northern (KY); Híbrido; USD 72 000 - 102 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

401(k) match

Health benefits

Educational assistance

Flexible vacation policy

Resumo da oferta

Gainwell Technologies seeks an Associate Manager, Clinical Quality to supervise quality assurance for Prior Authorization reviews and lead a team of auditors. You will ensure accuracy, timeliness, and regulatory compliance while driving performance metrics and improvements.

The role requires an RN license, 5+ years in healthcare quality and 2+ years in leadership, plus strong analytical and coaching skills. Remote U.S.

Qualificações

• Current, unrestricted RN license required.
• Minimum 5 years of experience in Prior Authorization, utilization management, clinical review, or healthcare quality assurance.
• Minimum 2 years of leadership or quality assurance experience in a health plan, managed care, utilization management, or healthcare setting.

Responsabilidades

• Supervise the Prior Authorization quality review program, including policies, procedures, and controls supporting compliance with standards, regulations, accreditation requirements, and contracts.
• Develop and maintain quality assurance processes, audit methodologies, and performance benchmarks for medical and behavioral health Prior Authorization reviews.
• Mentor clinical quality auditors and reviewers through education, coaching, and performance feedback; monitor and report quality, accuracy, timeliness, productivity, denial rationale, and interrater reliability metrics.
• Identify trends, root causes, and improvement opportunities in clinical criteria application, documentation, review consistency, and workflows.
• Analyze audit results, appeals, complaints, and regulatory findings to identify issues and recommend corrective actions.
• Prepare reports and dashboards for leadership on performance, audit outcomes, risks, and improvement initiatives.
• Ensure Prior Authorization reviews are completed accurately, consistently, and within required timeframes.
• Develop and deliver training based on audit findings, policy updates, and performance trends.
• Maintain knowledge of CMS, Medicaid, accreditation standards, clinical policies, and industry practices.
• Lead quality improvement initiatives that enhance accuracy, consistency, efficiency, and experience.
• Serve as a subject matter expert for new tools, automation, operational readiness, and escalated quality issues.
• Manage individual and team performance to meet or exceed performance standards.

Conhecimentos

Analytical

Communication

Coaching

Problem-solving

Formação académica

RN license

Descrição da oferta de emprego

Gainwell Technologies seeks an Associate Manager, Clinical Quality to supervise quality assurance for Prior Authorization reviews and lead a team of auditors. You will ensure accuracy, timeliness, and regulatory compliance while driving performance metrics and improvements.

The role requires an RN license, 5+ years in healthcare quality and 2+ years in leadership, plus strong analytical and coaching skills. Remote U.S.