Manager Quality Performance

Company :

Job Description : 

JOB SUMMARY

The Manager, Utilization Management (UM)  Quality Performance leads a team of quality auditors responsible for driving high-quality utilization management assessment for the Highmark utilization management department including non-clinical, medical, pharmacy and behavioral health for  commercial, Medicare advantage, ACA and CHIP products.

This role requires a strategic leader with strong analytical, project management, and communication skills to oversee UM quality performance, collaborating with multiple stakeholders to improve key performance indicators (KPIs) related to medical necessity, and other relevant UM quality metrics. 

The Manager will play a critical role in driving continuous improvement across the UM organization.

ESSENTIAL RESPONSIBILITIES

• Team Leadership & Management: 
  • Provide direct supervision to a team of quality auditors, including hiring, training, performance management, coaching, development, compensation, and recognition.
  • Oversee daily operations of quality activity, implement policies and procedures. 

• Strategic Planning & Execution: 
  • Collaborate with the Director to develop and implement the department’s strategic plan, aligning with organizational goals and objectives.
  • Regularly monitor and report on the plan’s progress to internal and external stakeholders, including regulatory bodies and business partners.

• Quality Performance Improvement: 
  • Oversee UM organization-wide quality improvement processes. 
  • Analyze performance data, identify areas for improvement, and develop and implement interventions to enhance quality and revenue.

• Cross-Functional Collaboration: 
  • Work collaboratively with clinical, pharmaceutical, operational, IT, and quality improvement teams across the enterprise to achieve organizational goals and optimize outcomes.
  • Partner with leadership to ensure program alignment with strategic objectives.

• Data Analysis & Reporting: 
  • Perform/lead analysis of enterprise-wide utilization management practices to identify opportunities for improvement.
  • Develop and maintain reporting mechanisms to track key performance indicators and communicate findings to stakeholders.

• Project Management: Oversee multiple projects simultaneously, managing timelines, budgets, and resources effectively. Escalate risks and dependencies to executive leadership as needed.

• Process Improvement: Continuously evaluate existing processes and implement improvements to enhance efficiency and effectiveness.

EDUCATION

Required

• Bachelor's Degree in Business Administration/Management or Health Care Related field

Substitutions

• High School Diploma with 6 years of experience

Preferred

• Master's Degree in Business Administration/Management or Health Care Related field

EXPERIENCE

Required

• 3 - 5 years of Quality Improvement experience
• 1 - 3 years of Project Management experience
• 1 - 3 years of Process Design experience
• 1 - 3 years of Process Improvement experience

Preferred

• Proven experience managing a team of quality auditors or a similar role in healthcare
• Strong understanding of utilization management principles
• Excellent analytical, problem-solving, and data interpretation skills
• Proficiency in project management methodologies
• Strong communication, interpersonal, and presentation skills
• 3 - 5 years of Strategic Planning experience
• 1 - 3 years of Operational Excellence experience
• 1 - 3 years of Medicare experience
• 1 - 3 years of Medicaid experience
• 1 - 3 years of Management experience

LICENSES OR CERTIFICATIONS

Required

• None

Preferred

• None

SKILLS

• Analytical Skills
• Performance Improvement
• Project Management
• Collaboration
• Written & Oral Presentation Skills
• Team Leadership
• Strategic Thinking
• Budget Management
• Healthcare Industry
• Vendor Management

Languages (other than English)

None

Travel Required

0% to 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office Based

Teaches / trains others regularly

Frequently

Travel regularly from the office to various work sites or from site-to-site

Occasionally

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required 

Yes

Lifting: up to 10 pounds

Occasionally

Lifting: 10 to 25 pounds

Rarely

Lifting: 25 to 50pounds

Rarely

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:

Pay Range Maximum:

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations.  The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. 

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