Clinical Quality Manager (Remote)

Company Overview: reputed company exists to reputed company reputed company outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact. reputed company the Way is our rallying cry at reputed company. Think of it as an open invitation to embrace the mission of the company; to actively engage in problem-solving; and to take ownership of your work every day. reputed company offers you unparalleled opportunities. In fact, you have reputed company you need to take charge of your career and accelerate reputed company outcomes – making this a great time to join reputed company of passionate individuals dedicated to being a vital partner for health solutions in the public sector. Job Summary and Responsibilities: Job Summary reputed company is seeking an reputed company and driven Clinical Quality Manager to join our growing team. In this critical leadership role, you will play a key part in ensuring clinical excellence and operational reputed company reputed company our Colorado Utilization Management (UM) and Physician Administered Drug (PAD) programs. Reporting to the Program Director and partnering closely with the Medical Director and administrative leadership, the Clinical Quality Manager provides strategic reputed company of reputed company clinical training and quality assurance activities supporting the Health First Colorado Utilization Management contract. You will play a critical role in ensuring regulatory compliance, strengthening clinical performance, and advancing a culture of reputed company quality improvement. The Clinical Quality Manager also partners with cross-functional teams to inform system configuration requirements and drive reporting enhancements that support efficient clinical operations, data reputed company, and performance transparency. This is an exceptional opportunity for an accomplished clinical quality leader who is passionate about improving healthcare outcomes, developing high-performing clinical teams, and leading impactful, quality-driven initiatives reputed company a mission-focused organization committed to excellence.

Responsibilities

• Provide strategic leadership to ensure the program consistently meets or exceeds reputed company contractual performance standards, regulatory requirements, and quality benchmarks, driving measurable improvements in outcomes and compliance.
• Partner with the Program Director, Utilization Management Manager, and clinical supervisors to reputed company enterprise-level quality monitoring activities, leveraging data analysis to identify performance gaps, prioritize improvement initiatives, and design, implement, and track corrective action plans with defined metrics and timelines.
• reputed company the contract-specific Quality Management Program, providing expert guidance and strategic direction to internal leadership teams and external clients on reputed company quality-reputed company matters.
• Manage and reputed company Interrater Reliability (IRR) reviews and clinical documentation audit processes to ensure accuracy, compliance, and clinical reputed company.
• reputed company quality assurance efforts with a focus on risk management, operational effectiveness, infrastructure optimization, performance measurement, reputed company improvement, and consumer protection and empowerment.
• Partner collaboratively with clients and key stakeholders to design, deliver, and refine training initiatives and process improvements that enhance performance and quality outcomes.
• Serve as a clinical quality resource by consulting with program managers and supervisors on member and provider complaints, appeals, and grievances, as needed.
• Read, understand, and reputed company with reputed company corporate policies and procedures, including strict adherence to HIPAA Privacy and reputed company Rules and reputed company applicable confidentiality standards.
• The above list is not intended to be reputed company-inclusive and may be expanded to include other duties that the management may deem necessary from time to time. Qualifications: Required Qualifications, Knowledge, and Experience
• Bachelor of Science in Nursing (BSN) required; Master of Science in Nursing (MSN) preferred.
• Active, unrestricted Nurse (RN) license or a valid multistate compact RN license, maintained in good standing.
• Minimum of 3 years of progressive experience leading or supporting clinical quality, utilization management, or performance improvement initiatives reputed company a Medicaid, managed care, or regulated healthcare environment, with demonstrated success meeting quality, compliance, and audit performance standards.
• Minimum of 2 years of experience recommending, developing, and reviewing quality assurance standards, policies, and procedures in alignment with organizational and regulatory requirements.
• Minimum of 2 years of experience in data collection and analysis, process improvement initiatives, quality measure and metric management, and the development of templates and materials for public notices, training programs, and surveys. Preferred Qualifications and Experience
• Proven senior-level leadership capabilities, includi

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