RN Quality Assurance Manager, Clinical Systems

CareOregon; United States; Hybrid; USD 141,000 - 172,000; Full time

Benefits offered by this job

Bonus - SIP Target 5%

Total rewards program

Job summary

CareOregon is seeking an RN Quality Assurance Manager, Clinical Systems to lead QA across clinical systems, ensuring compliant utilization management and high-quality content. You will oversee training, develop dashboards, and collaborate with Clinical Operations to align with Medicare/Medicaid requirements.

The role emphasizes cross-functional leadership, process improvement, and supervising staff to deliver timely, accurate QA outcomes while advancing organizational quality standards.

Qualifications

• Current unrestricted RN license for Oregon state.
• Minimum 5 years in health plan quality operations (quality assurance/utilization management).
• Preferred supervisory experience and familiarity with CareOregon programs.

Responsibilities

• Lead and supervise multiple quality assurance teams and projects.
• Develop, implement, and maintain QA testing of clinical content and processes.
• Ensure regulatory compliance and plans of correction across departments.
• Collaborate with Clinical Operations and Medical Directors on improvements.

Skills

RN license

Quality assurance

Utilization management

Project management

Training and development

Regulatory knowledge

Data analysis

Education

Registered Nurse (RN) license

Tools

InterQual

Medicaid/Medicare guidelines

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 - $172,260.00

Bonus Target:

Bonus - SIP Target, 5% Annual

Operations and Planning

• Develop 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 criteria
• Develop project plans, monitoring tasks and ensuring on-time delivery of clinical content.

Cross Functional Collaboration

• Works 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 Supervision

• Manages 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 Responsibilities

• Perform 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 Education

Required

• Current unrestricted Registered Nurse (RN) license for State of Oregon
• Minimum 5 years’ experience in health plan quality operations, such as member rights, quality assurance, and/or utilization management

Preferred

• Minimum 2 years’ experience in a supervisory position or minimum 1 year experience in a supervisory position with completion of CareOregon’s Aspiring Leaders Program
• Proficiency with nationally accepted clinical guidelines, such as InterQual or MCG
• Experience developing quality and testing programs, processes and procedures from the ground up
• Experience with applications and front and back-end system testing & technologies in multiple operating systems and environments
• Experience in clinical content creation or medical writing
• Experience with training and onboarding
• Experience directing vendor testing

Knowledge, Skills and Abilities Required

Knowledge

• Strong knowledge of health plan operations
• Knowledge of health plan regulatory requirements of Medicaid and Medicare managed care
• Knowledge of utilization management principles
• Knowledge of managed care concepts and principles
• Knowledge of organizational improvement principles and practices
• Knowledge of principles of organizational change and ability to act as a change agent
• Knowledge of quality improvement concepts, principles and practices

Skills and Abilities

• Excellent written and verbal communication skills
• Ability to work independently and as part of a team
• Strong attention to detail and organizational skills
• Ability to manage multiple projects and meet deadlines
• Basic understanding of software development phases
• Comprehensive skills in program development, management and evaluation
• Strong project management skills
• Strong statistical, analytical and problem-solving skills
• Ability to determine root problems
• Ability to create test requirements
• Strong detail-orientation, prioritization and organization skills
• Ability to work well under pressure in a complex and rapidly changing environment
• Self-motivated, adaptable to change and forward-thinking attitude
• Excellent spoken, written and presentation communication skills
• Excellent interpersonal skills
• Excellent leadership skills including the ability to coach, mentor and inspire staff working both onsite and remotely
• Skill in negotiation and conflict resolution
• Skill in collaboration and consensus building between and within departments
• Ability to lead and influence change and results
• Ability to work effectively with diverse individuals and groups
• Ability to maintain positive and professional relationships as a role model, leader and representative of CareOregon
• Ability to accept direction and feedback, as well as tolerate and manage stress
• Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day
• Ability to hear and speak clearly for at least 3-6 hours/day

Working Conditions

Work Environment(s): Indoor/Office Community Facilities/Security Outdoor Exposure

Member/Patient Facing: No Telephonic In Person

Hazards: May include, but not limited to, physical and ergonomic hazards

Equipment: General office equipment

Travel: 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 home

We 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.

We are an equal opportunity employer

CareOregon 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.