Remote Clinical Quality Lead – Prior Authorization

Gainwell Technologies LLC; Ohio; À distance; USD 72 000 - 102 000; Plein temps

Résumé du poste

Gainwell Technologies seeks an Associate Manager, Clinical Quality to supervise QA activities for Prior Authorization reviews and ensure accuracy, timeliness, and regulatory compliance. You will lead a team of auditors, monitor performance, and drive improvement initiatives that support evidence-based determinations and a positive provider and member experience.

You will develop processes, train staff, and report outcomes to leadership while maintaining knowledge of CMS, Medicaid, and industry

Qualifications

• RN license required; current, unrestricted RN license is required.
• Experience in Prior Authorization, utilization management, clinical review, or healthcare quality assurance.

Responsabilités

• Supervise the Prior Authorization quality review program, including policies, procedures, and controls.
• Develop QA processes, audit methodologies, and performance benchmarks for reviews.
• Mentor clinical quality auditors and reviewers through education and feedback.
• Identify trends, root causes, and improvement opportunities in criteria application and workflows.
• Analyze audit results, appeals, complaints, and regulatory findings for corrective actions.
• Prepare reports and dashboards for leadership on performance and risk.
• Ensure reviews are completed accurately, timely, and compliant with timeframes.
• Develop and deliver training based on findings and updates.
• Maintain knowledge of CMS, Medicaid, accreditation standards, and industry practices.
• Lead quality improvement initiatives to enhance accuracy and efficiency.
• Serve as SME for new tools, automation, and escalated quality issues.

Connaissances

Analytical skills

Communication

Coaching

Problem solving

Leadership

Quality assurance

Prior Authorization

Utilization management

Regulatory knowledge

Formation

Associate degree

Bachelor’s degree

Description du poste

Gainwell Technologies seeks an Associate Manager, Clinical Quality to supervise QA activities for Prior Authorization reviews and ensure accuracy, timeliness, and regulatory compliance. You will lead a team of auditors, monitor performance, and drive improvement initiatives that support evidence-based determinations and a positive provider and member experience.

You will develop processes, train staff, and report outcomes to leadership while maintaining knowledge of CMS, Medicaid, and industry