Senior Manager Business Excellence - Quality

Performance Management

• Leads the development, implementation, and governance of quality assurance and quality management programs across Clinical operations.
• Ensures objective and consistent monitoring of all customer and member interaction channels, including web, voice, email, chat, correspondence, and clinical case reviews.
• Establishes and monitors quality performance metrics, scorecards, and dashboards, identifying trends, opportunities, and risks through data-driven analysis.
• Provides actionable insights and quantifiable data to support quality evaluations, operational decision-making, and client reporting.
• Partners with Operations, Training, Workforce Management, Clinical Leaders, Medical Directors, and Support Functions to drive sustainable quality improvements and operational excellence.
• Oversees clinical quality monitoring activities, including utilization management (UM), care management (CM), prior authorization, appeals, grievances, and other healthcare operations, ensuring adherence to client, regulatory, and accreditation requirements.
• Ensures compliance with NCQA, CMS, URAC, state, federal, and client-specific standards through robust audit and monitoring programs.
• Conducts quality governance reviews, identifies emerging risks, develops corrective action plans, and tracks remediation efforts to closure.
• Acts as the primary quality liaison for clients and business partners, providing quality oversight, audit support, regulatory readiness, and resolution of quality-related concerns.
• Reviews and approves quality control documentation, standard operating procedures, audit tools, and process changes prior to implementation.
• Drives continuous process optimization through Lean, Six Sigma, Kaizen, and business transformation initiatives.
• Supports inter-rater reliability (IRR) programs, calibration activities, and auditor quality assurance to ensure consistency and accuracy of evaluations.
• Promotes member-centric quality outcomes through improved accuracy, compliance, turnaround time, service quality, and customer experience measures.

People Management

• Leads, mentors, and develops Quality Managers/Asst Managers, Quality Team Leads and auditors to achieve operational and quality objectives.
• Builds a high-performing quality culture through coaching, performance management, succession planning, and leadership development.
• Effectively manages organizational change, resolving resistance and aligning teams toward strategic quality initiatives.
• Conducts regular quality reviews, team meetings, calibration sessions, and knowledge-sharing forums to drive consistency and engagement.
• Provides subject matter expertise and coaching on healthcare quality standards, clinical audits, regulatory requirements, Lean, Six Sigma, and continuous improvement methodologies.
• Leads recruitment, onboarding, and capability development for quality and clinical quality resources.
• Conducts performance evaluations and career development planning for direct reports.
• Reviews employee relations concerns and disciplinary actions in accordance with company policies and procedures.
• Develops and facilitates training programs related to quality management systems, clinical auditing methodologies, quality tools, process excellence, and regulatory requirements.
• Serves as mentor and sponsor for Lean Six Sigma Green Belt, Black Belt, Kaizen, and Process Capability Studies (PCS) projects.
• Collaborates with operations and clinical leadership teams to improve quality competencies, clinical judgment consistency, and audit effectiveness.

Process Improvement

• Leads strategic quality improvement initiatives focused on operational excellence, clinical accuracy, compliance, efficiency, and member outcomes.
• Identifies opportunities through audits, root cause analysis, customer feedback, Voice of Customer (VOC), complaints, appeals, and quality monitoring programs.
• Develops and implements corrective and preventive action plans (CAPA) to address performance gaps and reduce operational risk.
• Drives process redesign, automation opportunities, standardization efforts, and best-practice adoption across healthcare operations.
• Establishes process health indicators, quality scorecards, and governance mechanisms to sustain improvement efforts.
• Partners with clients and operational leaders to improve contractual performance metrics, quality outcomes, regulatory compliance, and customer experience measures.
• Utilizes data analytics and process improvement methodologies to identify systemic issues and achieve measurable business impact.

Clinical Quality & Regulatory Oversight

• Oversees clinical quality audit programs, ensuring accuracy, consistency, and compliance of clinical decision-making and documentation.
• Supports readiness for client audits, accreditation reviews, and regulatory examinations.
• Evaluates compliance with clinical policies, medical necessity criteria, care management standards, and utilization management guidelines.
• Monitors quality indicators including accuracy, compliance, inter-rater reliability, turnaround time, first-pass quality, member satisfaction, and audit findings.
• Partners with Clinical Operations, Medical Directors, and Compliance teams to address clinical quality risks and implement remediation strategies.
• Ensures continuous alignment with evolving healthcare regulations, accreditation standards, and industry best practices.

Information Security, Safety, and Compliance

• Protects organizational assets by complying with the principles of the Quality and Information Security Management System (QISMS).
• Ensures the confidentiality, integrity, and availability of information in accordance with organizational, client, regulatory, and healthcare privacy requirements.
• Promotes compliance with HIPAA, data privacy regulations, information security policies, and business continuity requirements.
• Supports risk management initiatives and fosters a culture of quality, compliance, security, and accountability.