Supervisor, Clinical Quality Monitoring & Oversight

MedImpact Healthcare Systems, Inc.; United States; Remote; USD 64,000 - 111,000; Full time

Benefits offered by this job

Medical/Dental/Vision/Wellness

Paid Time Off / Holidays

Incentive Compensation

401K with Company match

Life and Disability Insurance

Tuition Reimbursement

Employee Referral Bonus

Job summary

MedImpact Healthcare Systems, Inc. is seeking a Supervisor, Clinical Quality Monitoring & Oversight to lead a PAQI team and supervise audit activities across all lines of business, ensuring compliance with accreditation standards.

The role reports to the Director of Accreditation & Clinical Quality Programs. The position requires a BS/BA degree (or equivalent), 2+ years of relevant experience, and at least 1 year of supervisory experience, with strong Excel and MS Office proficiency.

Qualifications

• Experience with Prior Authorizations and CMS Medicare Part D Coverage Determination, Redetermination, and IRE auto-forward requirements.
• BS/BA Degree or equivalent; 2+ years experience and 1 year supervisory experience.
• Advanced Excel skills and proficiency with MS Office applications.

Responsibilities

• Lead Clinical Quality Specialist team responsible for retrospective audits across lines of business.
• Oversee Medicare Part D late case reporting and IRE auto-forward processes.
• Develop and maintain performance reports, dashboards and trend analyses.

Skills

Prior Authorizations & Appeals

Leadership & Supervisory

CMS Medicare Part D knowledge

Education

BS/BA Degree or equivalent

Tools

Microsoft Office Suite

Excel

Word

Outlook

PowerPoint

Teams

Job description

Exemption Status:

United States of America (Exempt)

$64,269 - $87,568 - $110,866

“Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors. A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate.”

This position is not eligible for Sponsorship.

MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team!

Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare.

At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution!

Job Description

Summary

The Supervisor, Clinical Quality Monitoring & Oversight leads a team of Clinical Quality Specialists (PAQI team) and supervises the clinical quality monitoring and oversight activities of the Accreditation, Quality & Utilization Review (AQUR) department. This is done in accordance with State, Federal, client contractual, and accreditation requirements. Reporting to the Director, Accreditation & Clinical Quality Programs, the Supervisor runs the day-to-day execution of the department’s retrospective case file audit, Medicare Part D late case and IRE auto-forward reporting, performance guarantee validation, and quality reporting activities across all lines of business and utilization management platforms. The Supervisor serves as the department’s subject matter expert on audit methodology and quality reporting, and partners with the department’s Clinical Quality Pharmacists and AQUR Specialists.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Leads the Clinical Quality Specialist team responsible for retrospective quality and compliance audits of prior authorization and appeal determinations across all lines of business, utilization management platforms, reviewer types, and delegated entities, overseeing audit sampling, workload, performance, accuracy, turnaround, and reporting.

• Oversees the Medicare Part D late case and IRE auto-forward reporting process.

• Leads cross-functional operational meetings with PA, Appeals, and audit leadership to address priorities, resolve issues, and drive alignment.

• Develops and maintains accurate, timely performance reports, trend analyses and dashboards to monitor key metrics, identify trends and support decision making.

• Maintains and standardizes the department’s audit tools, scoring criteria, sampling standards, and work instructions to ensure consistent application across legacy and acquired operating entities and all utilization management platforms.

• Supports the delegation oversight program.

• Supports administration of the Inter-Rater Reliability (IRR) program.

• Supports targeted audits of drug categories, clinical programs, & regulatory changes.

• Supports client oversight audits, regulatory audits and NCQA & URAC accreditation surveys.

• Executes the annual monitoring and audit work plan.

• Manages team’s shared mailboxes and inquiry queue.

• Recommends and implements operational improvements to enhance audit quality, efficiency, and compliance with regulatory and accreditation standards.

• Other duties may be assigned.

Supervisory Responsibilities

Manages assigned staff in the segment area. Responsible for the overall direction, coordination, and evaluation of the unit. Carries out supervisory responsibilities in accordance with the organization’s policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems. Supports and enforces all company policies and procedures in a fair and consistent manner, taking corrective action whenever necessary.

Client Responsibilities

This is an internal and external client facing position that requires excellent customer service skills and interpersonal communication skills (listening/verbal/written). One must be able to; manage difficult or emotional client situations; Respond promptly to client needs; Solicit client feedback to improve service; Respond to requests for service and assistance from clients; Meet commitments to clients.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

BS/BA Degree or equivalent; 2+ years of experience (or equivalent combination of education and experience) and 1 year of supervisory experience. Supervisory experience may be substituted with two (2) years of MedImpact experience plus an appropriate external leadership training program and internal mentorship with a seasoned leader at the Director level or above that must be completed within 12 months in new position.

Computer Skills

Microsoft Office Suite (Word/Excel/Outlook/PowerPoint), Teams, and standard PDF document tools, including the ability to create, annotate, and complete fillable PDF documents. Advanced Excel skills (pivot tables, lookups, data validation) for audit tracking, sampling, and rate calculation required. Working knowledge of prior authorization and appeals adjudication platforms, enterprise document management, and quality reporting systems is preferred.

Certificates, Licenses, Registrations

An active, unencumbered Pharmacy Technician license or registration in at least one U.S. state and/or current national certification (CPhT, through PTCB or NHA) is strongly preferred. Certified Professional in Healthcare Quality (CPHQ) or an equivalent quality, compliance, or managed care certification is a plus.

Other Skills and Abilities

• Previous experience with Prior Authorizations and/or Appeals and CMS Medicare Part D Coverage Determination, Redetermination, and IRE auto-forward requirements.

• Working knowledge of NCQA Utilization Management and/or URAC Pharmacy Benefit Management accreditation standards and of State utilization review licensure requirements preferred.

Reasoning Ability

• Ability to define problems, collect data, establish facts, and draw valid conclusions.

• Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.

Mathematical Skills

• Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.

Language Skills

• Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.

• Ability to write reports, business correspondence, and procedure manuals.

Competencies To perform the job successfully, an individual should demonstrate the following competencies:

Building Effective Teams

Decision Quality

Informing

Confronting Direct Reports

Delegation

Organizational Agility

Customer Focus

Drive for Results

Political Savvy

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit and talk or hear. The employee is regularly required to stand; walk; use hands to finger, handle, or feel and reach with hands and arms. The employee must occasionally lift and/or move up to 25 pounds. Ability to maintain clear near visual acuity at approximately 20 inches or less (i.e., “close vision”) to accurately read fine print, view computer screens, and handle small objects. Requires adequate color vision and depth perception to support safety and precision in detail-oriented tasks.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

This position may regularly be exposed to or encounter moving mechanical parts, high, precarious places, fumes, or airborne particles, toxic or caustic chemicals, outdoor weather conditions, risk of electrical shock or vibration. The noise level in the work environment is usually moderate (examples: business office with computers and printers, light traffic).

Work Location

This position works on-site at the San Diego Headquarters or other company location (or from a remote location with management approval based on business requirements). Must provide adequate support to internal clients; be available for regular interactions and coordination of work with other employees, colleagues, clients, or vendors; as well as be available to facilitate effective decisions through collaboration with stakeholders.

Working Hours

This is an exempt level position requiring the incumbent to work the hours required to fully accomplish job responsibilities and meet deadlines for work deliverables. The individual must have the flexibility to work beyond traditional hours and be able to work nights, weekends or on holidays as required. Work hours may be changed from time to time to meet the needs of the business. Typical core business hours are Monday through Friday from 8:00am to 5:00pm.

Travel

This position requires no travel; however, attendance may be required at various local conferences and meetings.

The Perks:

• Medical / Dental / Vision / Wellness Programs

• Paid Time Off / Company Paid Holidays

• Incentive Compensation

• 401K with Company match

• Life and Disability Insurance

• Tuition Reimbursement

• Employee Referral Bonus

MedImpact, is a privately-held pharmacy benefit manager (PBM) headquartered in San Diego, California. Our solutions and services positively influence healthcare outcomes and expenditures, improving the position of our clients in the market. MedImpact offers high-value solutions to payers, providers and consumers of healthcare in the U.S. and foreign markets.

Equal Opportunity Employer, Male/Female/Disabilities/Veterans

OSHA/ADA:

To perform this job successfully, the successful candidate must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Disclaimer:

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.