RN Quality Assurance Manager, Clinical Systems

CareOregon; Portland (OR); Remote; USD 141,000 - 172,000; Full time

Benefits offered by this job

Bonus - 5% SIP Target

Job summary

CareOregon is seeking an RN Quality Assurance Manager for Clinical Systems to lead QA for decision tools used in utilization management. You will oversee multiple teams, collaborate with Clinical Operations, and drive internal QA processes, dashboards, and vendor testing to meet quality standards and compliance.

You will train staff, implement improvements, and manage documentation while ensuring alignment with Medicare/Medicaid guidelines and organizational goals.

Qualifications

• Current unrestricted RN license for Oregon.
• 5+ years in health plan quality operations or utilization management.
• Experience with clinical content and testing.
• Experience directing vendor testing and QA processes.
• Strong knowledge of regulatory requirements (Medicare/Medicaid) and quality improvement.

Responsibilities

• Lead and supervise multiple QA teams for clinical systems and decision tools.
• Develop and maintain QA testing processes, dashboards, and reports.
• Coordinate with Clinical Operations and other CareOregon teams.
• Ensure compliance with regulatory and contractual requirements.
• Provide training and remediation outcomes across departments.

Skills

Leadership

Quality Assurance

Utilization Management

Training

Data Analysis

Project Management

Communication

Change Management

Clinical Content Creation

Vendor Testing

Education

RN License (Oregon)

Tools

InterQual

MCG

Job description

RN Quality Assurance Manager, Clinical Systems-This position is responsible for providing leadership oversight in the correct and effective use of decision tools used for utilization management activities including staff training. The position is responsible for managing multiple teams and resources. They work collaboratively with Clinical Operations and other CareOregon Teams to ensure integration and support of organizational activities and goals across all lines of business. The position is responsible for department planning, as well as developing, implementing and managing internal operations and vendor transactional quality assurance processes, reports, dashboards and workflows to ensure CareOregon’s quality standards are achieved, and compliance requirements are met. Additionally, the role is responsible for communicating results, process improvements and remediation outcomes both laterally and horizontally.Estimated Hiring Range:$140,940.00 - $172,260.00Bonus Target:Bonus - SIP Target, 5% AnnualCurrent CareOregon Employees: Please use the internal Workday site to submit an application for this job.-Operations and PlanningDevelop and oversee implementation of (department) policies and procedures.Develops and oversees training documents, audit materials and educational resources.Conduct process trainings.Assist the Director in long- and short-term quality planning.Assure clinical systems align with regulatory and contractual requirements (Medicare and Medicaid) and organizational needs.Design, develop, and update clinical content through the review and understanding of information gathered from regulatory and organizational requirements.Develop Quality Assurance testing of clinical content and create and maintain documentation.Create and maintain tools and processes to verify accuracy and effectiveness of clinical systems.Analyze data and information to identify improvement opportunities and recommend changes/enhancements to processes.Develops and implements strategies to ensure compliance with internal and external plans of correction.Maintains records that demonstrate compliance with regulatory requirements and/or plans of correction.Keep abreast of regulatory expectations (state, federal and health plan) and inform staff and other stakeholders of these requirements.Keep abreast of standards for health plan quality operations related to responsible areas and develop plans to operationalize.Utilizes Quality Improvement methodologies as part of continuous improvement including root cause analysis, Plan/Do/Study/Act.Utilizes change management methodologies to communicate required changes to staff and other teams.Prepare internal business reviews and presentations as needed.Maintain up-to-date knowledge of clinical practices and Medicare and Medicaid guidelines.Serve as a clinical resource for both internal and external customers, including training of new content both created and as part of the product.Collaborate with Medical Directors and Clinical Operations leadership team for organizational criteriaDevelop project plans, monitoring tasks and ensuring on-time delivery of clinical content.Cross Functional CollaborationWorks collaboratively with other CareOregon leaders and departments.Participates in internal and external workgroups/meetings as required.Assures stakeholders are engaged in performance improvement processes.Develops a matrixed relationship with other Quality Assurance Leaders as necessary to assure efficient departmental functioning.Provides cross coverage for other departmental leaders.Assists in internal and external audits are requested.Employee SupervisionManages team and recommend team direction and goals in alignment with the organizational mission, vision, and values.Identify work and staffing needs to meet work expectations; recruit and hire, using an equity, diversity, and inclusion lens.Plan, organize, schedule, and monitor work; ensure employees have information and resources to meet job expectations.Lead the development, communication, and oversight of team and individual goals; ensure goals, expectations, and standards are clearly understood by staff.Train, supervise, motivate, and coach employees; provide support toward employee development.Incorporate guidance from CareOregon equity tools into people leadership, planning, operations, evaluation, and decision making.Utilize CareOregon’s competencies to evaluate employee performance and provide regular feedback to support success; recognize strong performance and address performance gaps and accountability (corrective action).Perform supervisory tasks in collaboration with Human Resources as needed.Organizational ResponsibilitiesPerform work in alignment with the organization’s mission, vision and values.Support the organization’s commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals.Strive to meet annual business goals in support of the organization’s strategic goals.Adhere to the organization’s policies, procedures and other relevant compliance needs.Perform other duties as needed.Experience and/or EducationRequiredCurrent unrestricted Registered Nurse (RN) license for State of OregonMinimum 5 years’ experience in health plan quality operations, such as member rights, quality assurance, and/or utilization managementPreferredMinimum 2 years’ experience in a supervisory position or minimum 1 year experience in a supervisory position with completion of CareOregon’s Aspiring Leaders ProgramProficiency with nationally accepted clinical guidelines, such as InterQual or MCGExperience developing quality and testing programs, processes and procedures from the ground upExperience with applications and front and back-end system testing & technologies in multiple operating systems and environmentsExperience in clinical content creation or medical writingExperience with training and onboardingExperience directing vendor testingKnowledge, Skills and Abilities RequiredKnowledgeStrong knowledge of health plan operationsKnowledge of health plan regulatory requirements of Medicaid and Medicare managed careKnowledge of utilization management principlesKnowledge of managed care concepts and principlesKnowledge of organizational improvement principles and practicesKnowledge of principles of organizational change and ability to act as a change agentKnowledge of quality improvement concepts, principles and practicesSkills and AbilitiesExcellent written and verbal communication skillsAbility to work independently and as part of a teamStrong attention to detail and organizational skillsAbility to manage multiple projects and meet deadlinesBasic understanding of software development phasesComprehensive skills in program development, management and evaluationStrong project management skillsStrong statistical, analytical and problem-solving skillsAbility to determine root problemsAbility to create test requirementsStrong detail-orientation, prioritization and organization skillsAbility to work well under pressure in a complex and rapidly changing environmentSelf-motivated, adaptable to change and forward-thinking attitudeExcellent spoken, written and presentation communication skillsExcellent interpersonal skillsExcellent leadership skills including the ability to coach, mentor and inspire staff working both onsite and remotelySkill in negotiation and conflict resolutionSkill in collaboration and consensus building between and within departmentsAbility to lead and influence change and resultsAbility to work effectively with diverse individuals and groupsAbility to maintain positive and professional relationships as a role model, leader and representative of CareOregonAbility to accept direction and feedback, as well as tolerate and manage stressAbility to see, read, and perform repetitive finger and wrist movement for at least 6 hours/dayAbility to hear and speak clearly for at least 3-6 hours/dayWorking ConditionsWork Environment(s): Indoor/Office Community Facilities/Security Outdoor ExposureMember/Patient Facing: No Telephonic In PersonHazards: May include, but not limited to, physical and ergonomic hazardsEquipment: General office equipmentTravel: May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used.Work Location: Work from homeWe offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information.We are an equal opportunity employerCareOregon is an equal opportunity employer. The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.