POSITION SUMMARY

The Manager, Quality and Accreditation is responsible for leading organizational quality improvement initiatives and ensuring ongoing compliance with accreditation and regulatory standards. This role oversees the development and facilitation of training strategies, manages quality data abstraction for NCQA HEDIS measures, CAHPS, and HOS surveys, and collaborates with internal stakeholders to close gaps and achieve performance targets. The Manager also coordinates accreditation readiness activities, ensuring policies, procedures, and operations meet or exceed standards set by NCQA, state, federal, and other governing bodies.This position plays a pivotal role in aligning operational performance with quality outcomes, supporting audit preparedness, and promoting a culture of compliance and continuous improvement across the organization.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

• Maintains strong working knowledge of National Committee for Quality Assurance (NCQA) Health Plan standards, MM department/ clinical policies and established workflows to inform quality assurance reviews, recommendations, and education.
• Oversee abstraction of NCQA HEDIS measures, CAHPS, and HOS surveys to monitor quality performance and identify gaps.
• Performs root cause analysis, identifying opportunities for improvement, implementing case-specific service recovery, and applicable corrective action plan of Member, provider, broker complaints related to internal MM services and delegated vendor services.
• Oversight of vendor related activities and relationships, ensuring vendor compliance with internal benchmarks, SLAs, and accreditation requirements.
• Tracks, monitors, and reports trends, impact, action, and outcomes of opportunities for improvement based on audit, complaint, IRR and appeal results.
• Analyze audit findings, develop corrective action plans, and collaborate with operational teams to improve outcomes.
• Timely submission of all applicable departmental policy/procedures, reports and updates.
• Ensures all applicable reports and updates are prepared for timely submission to applicable committees
  • (Quality Assurance, Medical Management, Compliance, Complaints and Appeals).

• Manage annual policy and procedure reviews to ensure alignment with regulatory and accreditation requirements.
• Any other project work or supportive duties as assigned.

JOB SPECIFIC KEY COMPETENCIES (KSAs)

• Direct experience with NCQA, URAC, CMS Stars, HEDIS, CAHPS, and HOS programs.
• Proven experience leading audits, accreditation surveys, and quality improvement initiatives.
• Able to work independently with minimal supervision.
• Ability to manage multiple priorities and meet tight deadlines in a fast-paced environment.
• Appreciation of cultural diversity and sensitivity towards individual preferences and needs of Member population.
• Proficient in English with verbal, written, interpersonal and public communications.
• Proficient with Microsoft Office products, typing, and ability to maintain accurate clinical documentation; ability to develop high quality reports for presentation to key internal/external stakeholders.
• Ability to maintain production levels and quality standards with minimal supervision.

DIVERSITY, EQUITY, AND INCLUSION STATEMENT

Community Health Options is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion (DEI). Our human capital is the single most valuable asset we have. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent our employees invest in their work represents a significant part of not only our culture, but our reputation and achievement as well. Community Health Options DEI initiatives are applicable, but not limited to, our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of DEI, which encourages and enforces:

• Respectful, open communication and cooperation between all employees.
• Teamwork and participation, encouraging the representation of all groups and employee perspectives.
• Balanced approach to work culture through flexible schedules to accommodate varying needs of our people.
• Employer and employee contributions to the communities we serve to promote a greater understanding and respect for each other.

QUALIFICATIONS AND CORE REQUIREMENTS

• Bachelor's Degree preferred.
• Minimum 3-5 years clinical experience, required.
• Unrestricted Compact or Maine registered nurse license, required.