Manager, Clinical Quality Monitoring & Oversight

Exemption Status: United States of America (Exempt) $81,581 - $110,136 - $138,690 “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 Manager of Clinical Quality Monitoring and Oversight is a licensed clinician responsible for managing the clinical monitoring and oversight activities of the Accreditation, Quality & Utilization Review (AQUR) department in accordance with State, Federal, client contractual, and accreditation requirements. The Manager directs the department’s retrospective case audit, delegation oversight, and inter-rater reliability programs across all lines of business and utilization management platforms and manages a multidisciplinary team of clinical and non-clinical quality staff with a Lead/Supervisor directly reporting to the position. The Manager serves as the second-level clinical authority for the department and provides continuity of departmental leadership in the absence of the Director. Essential Duties and Responsibilities include the following. Other duties may be assigned. Manages a multidisciplinary team performing clinical monitoring and oversight of technician, pharmacist, and physician reviewers in the PA and Appeals departments and of delegated utilization management entities, across all lines of business (Commercial, Medicare Part D, Medicaid, and Marketplace) and utilization management platforms. Oversight includes preparation of quality performance reports supporting Health Services, enterprise governance committees, and client reporting obligations. Represents the Clinical Quality team in cross-departmental, committee, and client-facing meetings and acts on behalf of the Director in the Director’s absence. Leads and participates in interdepartmental meetings with Leadership, providing knowledge of  processes, audit data and trends, and accreditation and regulatory requirements. Leads audits of case reviews performed by prior authorization coordinators, clinical pharmacists, physician reviewers, Appeals staff, and delegated utilization management entities across all lines of business. Manages the delegation oversight program, including annual delegate audits, corrective action plan issuance, and monitoring of corrective actions through closure, and supports pre-delegation evaluations. Oversee inter-rater reliability testing for clinical and non-clinical reviewers and applies results to reviewer education, criteria clarification, and process improvement. Directs targeted audits of high-cost drug categories, high-risk clinical programs, and other identified risk areas, and presents findings and recommendations to leadership and governance committees. Performs root cause analysis that requires the entry, collecting, interpretation, and presentation of  data internally and externally of MedImpact. Recommends and implements operational improvements to enhance clinical quality, efficiency, and compliance with regulatory and accreditation standards. Responsible for validating and reporting prior authorization metrics in alignment with performance guarantees. Develops, maintains, and enforces Clinical Quality policies, assists with Quality Management and Utilization Management Programs, and represents the department on relevant committees, including the Quality Improvement Committee (QIC), Utilization Management Oversight Committee (UMOC), and Clinical Performance Management Committee (cPMC). Analyze untimely Part D cases and assess operational defects, driving corrective actions and quality initiatives to improve outcomes. Develops the compliance monitoring and auditing work plan to address potential risk areas to be reviewed, including risks associated with the Part D benefit. Supports maintaining MedImpact’s and its Clients’ NCQA and URAC Accreditations and supports State utilization review licensure (URL) application, reporting, and audit requirements. Supports client oversight audits, corrective action plan responses, and delegation-related client inquiries in coordination with the Director, Account Management, and Corporate Compliance. Ensures monitoring methodology, sampling standards, and audit scoring criteria are defined, documented, and consistently applied across legacy and acquired operating entities and platforms. Hires, manages, mentors, and develops staff both directly and through a subordinate Lead/Supervisor, providing guidance on career development, performance, and personnel decisions; develops subordinate leaders and maintains a succession plan for key department roles. Fosters a collaborative culture within the department and across teams to achieve business objectives. Other duties as assigned. Supervisory Responsibilities