Clinical Quality Manager - Regulatory & Accreditation - Remote in NC

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together

This position provides for management of the organizational quality management program as a core service to Community & State Plans in a highly complex and at-risk environment. The Quality Manager - Regulatory & Accreditation works within highly matrixed relationships to ensure full implementation of the annual quality management program, inclusive of an annual Quality Management and Improvement Program (QMIP) and a Quality Improvement Work Plan (QIWP) that  considers opportunities identified in the prior year program Quality Improvement Evaluation (QIE).  The program, and its various operational components, will comply with all state Medicaid and any associated federal regulatory requirements.  

This position develops and maintains strong relationships with state regulators as applicable.  It further collaborates with staff of multiple departments that may include Clinical, Physician Engagement, Member Experience, Benefit Design/Product, Compliance, Network, Behavioral Services, and Pharmacy as needed to support quality management program initiatives.  Lastly, the  actively supports the development of content in support of RFP submission, as may be pursued.

If you are located in NC, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

• Partner with Director of Quality and other UHC Community Plan of North Carolina health plan leaders to ensure development and complete implementation of the annual Health Plan Quality Management Program, inclusive of adequate quality oversight processes and comprehensive quality committee structure
• Foster and maintain productive and collaborative relationships with the state of North Carolina Department of Health Benefit (DHB) quality personnel
• Act as a subject matter expert regarding NCQA® Health Plan and Health Equity accreditation and state regulatory requirements deemed in scope for Quality
• Establish an annual reporting calendar which enables proactive organizational work on report production that facilitates ability for internal review no less than three weeks prior to internal due dates and actual submission in accordance with timelines established by the health plan
• Oversee the process of producing assigned QAV/Quality reports to DHB's specifications
  • Take steps to ensure validity of data and/or narrative content prior to submission by engaging appropriate SMEs
  • Escalate when identified issues remain unresolved in a timeframe that enables correction prior to due date
• Act as lead on creation and submission of
  • The annual QMIP and QIWP
  • The Annual Quality Assessment and Performance Improvement (QAPI)
• Oversee the submission of the Performance Improvement Plans (PIPs)
• Develop quality operational policies and procedures (P&Ps) as needed to ensure uniformity/consistency of operations
• Monitor the effect of the quality committee structure and collaborate with health plan leaders to revise as needed to acknowledge organizational needs
• Convey expectations regarding use of tools in establishing uniformity in approach when committee meetings are held, such as presentation of data, indication of action taken/to be taken, and evaluation of effect of action taken, as appropriate
• Work with National contact to establish accreditation project plan, indicating actions needed at the Element and/or Factor level
• Direct the engagement and education of various health plan functional areas in producing needed evidence to demonstrate compliance to NCQA®, EQRO, and DHB accreditation/audit/oversight requirements deemed in scope for Quality
  • Initiate and assess status of corrective action plans as needed  
• Supervise other Quality Department staff as indicated in organizational design

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• 2+ years of leading an integrated and progressive quality program, preferably within health care industry
• 2+ years of demonstrated functional knowledge related to regulatory adherence of a quality management program, NCQA® accreditation, EQRO oversight audits, state Medicaid reporting, quality committee management
• 1+ years of supervisory, team leader, or management experience
• 1+ years excellent relationship building skills and performance/results driven
• 1+ years of experience presenting to executives using advanced written and verbal communication skills
• 1+ years of knowledge of the managed care/health insurance industry, products and services
• Advanced computer skills, knowledge of MS Office products
• Must be willing to travel within the state of North Carolina up to 25%

Preferred Qualifications:

• Master's degree in a health-related field
• Knowledge of North Carolina Medicaid
• Local candidates to the state of North Carolina
• Proven solid influencing and negotiation skills with the ability to make independent decisions
• Proven solid team building, collaboration and motivational skills

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $91,700 to $163,700 annually based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.