UM Quality Manager-Medicaid

  • Full-time
  • $75k-$100k/mo
  • a month ago
Quality Assurance
Acentra seeks a UM Quality Manager-Medicaid (Remote U.S.) to join our growing team.
Job Summary:
  • Under general supervision of the Program Director and in collaboration with the administrative team and Medical Director, the Quality Manager oversees the department responsible for internal and external Quality Review processes in accordance with the goals of the Colorado HCPF Utilization Management Contract.
  • The Quality Manager also assists with the development of requirements for system configuration and reports.
Job Responsibilities:
  • Ensure that the program meets or exceeds all contract Performance Standards.
  • In collaboration with the Program Director, UM Manager, and clinical supervisors, responsible for the quality monitoring activities, including identifying areas of improvement and plan implementation of improvement areas.
  • Oversee contract-specific Quality Program, providing guidance to the management team and client regarding quality-related issues.
  • Focus on risk management, operations and infrastructure, performance monitoring and improvement, and consumer protection and empowerment in the day-to-day management of quality assurance activities for the contract.
  • Manage program staff IRR and clinical documentation audit processes.
  • Work collaboratively with clients and stakeholders to develop process improvements.
  • Verify adverse decision notifications were handled and documented per the policies of the state of Colorado.
  • Consult with other program managers and supervisors regarding member and/or provider complaints and grievances as needed.
The above list is not intended to be all-inclusive and may be expanded to include other duties that the management may deem necessary from time to time.


Required Qualifications/Experience:
  • Bachelor’s degree in Nursing.
  • An active, unrestricted Registered Nurse (RN) license in any U.S. state.
  • Clinical experience.
  • 3+ years of experience in quality management and project management.
  • 2+ years of experience recommending, developing, and reviewing quality assurance standards, policies, and procedures in accordance with company standards.
  • Experience working in a Fee-for-Service (FFS) or Managed Care Medicaid quality role.
  • 2+ years of experience in data collection, process improvement, ensuring quality measures/metrics, and template creation for public notices, training, and surveys.
  • 3+ years of experience in Utilization Management (UM) / Utilization Review (UR).
  • 3+ years of experience working with external clients and customers.
  • Set high standards of performance for self and others and assume responsibility and accountability for successfully completing assignments or tasks.
  • Knowledge of National Committee for Quality Assurance (NCQA) / Utilization Review Accreditation Commission (URAC) standards.
  • Ability to maintain a positive attitude and contribute both as an individual and a team member to achieving the department's goals.
  • Ability to professionally respond to change and handle multiple and changing priorities with sometimes conflicting deadlines.
  • Knowledge and willingness to become a subject matter expert and thought leader for the designated program(s).
  • Demonstrated proficiency in MS Office applications.
  • Excellent verbal and written communication skills.
  • Highly organized.
  • Excellent customer service skills.
Preferred Qualifications/Experience:
  • Master’s in Nursing or another health-related field.
  • Certified Professional in Healthcare Quality (CPHQ).
  • 5+ years of experience in quality management and project management.
  • 3+ years of experience working with a Medicaid population.
  • Experience with State Medicaid programs.
  • Knowledge of Colorado Medicaid.
  • Experience in services such as DME, Medical/Surgical, Psych/BH, Pediatric Home Health/PDN, Physician Administered Drugs, and other outpatient services.
Why us?
We are a team of experienced and caring leaders, clinicians, pioneering technologists, and industry professionals who come together to redefine expectations for the healthcare industry. State and federal healthcare agencies, providers, and employers turn to us as their vital partner to ensure better healthcare and improve health outcomes.
We do this through our people.
You will have meaningful work that genuinely improves people's lives nationwide. Our company cares about our employees, giving you the tools and encouragement, you need to achieve the finest work of your career.
Thank You!
We know your time is valuable, and we thank you for applying for this position. Due to the high volume of applicants, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in Acentra Health and invite you to apply to future openings that may interest you. Best of luck in your search!
~ The Acentra Health Talent Acquisition Team
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EOE AA M/F/Vet/Disability
Acentra Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by applicable Federal, State, or Local law.


Benefits are a key component of your rewards package. Our benefits are designed to provide additional protection, security, and support for your career and life away from work. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts, and more.
The pay range for this position is $86,000-91,000
“Based on our compensation philosophy, an applicant’s placement in the pay range will depend on various considerations, such as years of applicable experience and skill level.”