Sr. Manager, Program Management Clinical

Your Role 

The Quality Review team completes audits of front-line staff to ensure alignment with department processes and regulatory compliance. The Quality Review team also provides coaching and works closely with business leaders to drive optimal results. The Sr. Manager, Clinical Quality Review, will report to the Director, Program Management Clinical. In this role you will be providing oversight and leadership to the Quality Review team by evaluating performance, tracking to team goals, and ensure that staff have the skills and knowledge required to be successful in their auditing duties and maintaining target productivity.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Work

In this role, you will:

• Lead a high-performing team by setting clear goals, providing guidance, and driving strategies aligned with organizational objectives. Foster accountability, collaboration, and continuous learning to achieve operational excellence.
• Ensure team compliance with best practices and regulatory requirements while developing innovative approaches to enhance quality assurance processes.
• Establish and monitor team goals and monthly targets. Implement streamlined reporting to track progress, identify barriers, and recommend improvements while maintaining fiscal responsibility.
• Perform clinical audits as needed to ensure team compliance with regulatory standards, internal policies, and quality assurance of business requirements.
• Identify process improvement opportunities to optimize team performance.
• Build strategic relationships with stakeholders to ensure successful HQA quality assurance outcomes and assess audit needs across business functions.
• Communicate audit finding trends to business leaders and collaborate with training facilitators to drive quality assurance and continuous improvement.
• Oversee annual NCQA Inter-Rater Reliability requirements, processes, and reporting.
• Present Quality Review Team processes and outcomes during regulatory audits and committee meetings.
• Ensure consistent year-over-year performance with audits meeting or exceeding targets
• Coach and develop the Quality Review team, fostering growth and engagement.

Your Knowledge and Experience

• Requires at least 10 years of prior relevant experience including 4 years of direct people management experience.
• Bachelor of Science in Nursing or advanced degree preferred
• Requires a current California RN License.
• Strong understanding of Blue Shield of California lines of business and Health Solutions Operations as related to various regulatory (NCQA, DMHC, DHCS, CMS) and internal compliance requirements preferred.
• Strategic thinking and decision-making.
• Proficiency in management and process improvement.
• Ability to manage complex projects and competing priorities.
• Strong communication and presentation skills.