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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in compliance with CMS and NCQA standards, along with strong analytical skills for data manipulation and reporting. Proven ability to lead quality improvement projects and facilitate committee meetings in post-acute health care settings.
Highest-signal resume keywords
Compliance With CMS StandardsNCQA UM Accreditation KnowledgeQuality Improvement Project LeadershipData Analysis And ReportingClinical Expertise In State And Federal Regulations
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Utilization ManagementQuality ImprovementData AnalysisAudit ConductingPerformance MeasurementRegulatory ComplianceReport GenerationClinical DocumentationSLA ManagementTrend Analysis
Soft Skills
PrioritizationPlanningMultitaskingCommunicationLeadership
Certifications & Qualifications
Active RN LicenseActive PT LicenseActive OT LicenseActive SLP License
Industry Keywords
Post-Acute Health CareLTACHIRFSNFHome HealthQuality Improvement ProgramAccreditation StandardsRegulatory ChangesCommittee MeetingsCorrective Action Plans
About the role
Key responsibilities & impact- Ensure compliance with WellSky's Utilization Management and Quality Improvement Program
- Serve as a clinical expert on state and federal regulations
- Analyze and present data to establish best practices across post-acute health care settings, including LTACHs, IRFs, SNFs, and Home Health facilities
- Facilitate performance measurement and outcomes activities
- Ensure compliance with CMS, NCQA, and other regulatory standards
- Monitor relevant regulatory changes and support their integration into practices
- Generate and validate reports across health plan contracts
- Conduct audits of UM decisions, case documentation, turnaround times, and CMS/NCQA requirements
- Ensure the UM Program meets NCQA accreditation requirements
- Prepare and lead monthly and quarterly committee meetings
- Prepare quality reports, analyze trends, and present actionable recommendations to leadership
- Support corrective action plans when scoring variances occur
- Support quality improvement project initiatives
- Prepare for regulatory, accreditation, and contractual audits
- Contribute to remediation and documentation of audit findings
- Perform other assigned duties
Requirements
What you’ll need- At least 4-6 years relevant work experience
- Experience leading quality improvement projects and committee work
- Bachelor's Degree or equivalent work experience
- Active, unrestricted license: RN, PT, OT or SLP, with a bachelor’s degree in a related field or a combination of education and experience that includes pertinent clinical experience and advanced working knowledge of CMS standards and guidelines
- At minimum, 1-2 years of working knowledge of NCQA UM accreditation standards
- Ability to prioritize, plan and handle multiple tasks and demands simultaneously, with competing deadlines
- Excellent in manipulating and sorting data for analytics and reporting
- Prior experience owning client compliance SLAs and ensuring success in meeting SLA requirements
- Willingness to work additional or irregular hours as needed
- Must work in accordance with applicable security policies and procedures to safeguard company and client information
- Must be able to sit and view a computer screen for extended periods of time
- Travel approximately 10%
- Applicants for U.S.-based positions must be legally authorized to work in the United States
Benefits
Comp & perks- Excellent medical with Rx, dental, and vision benefits
- Mental Health support through EAP
- Generous paid time off
- 13 paid holidays
- 100% vested 401(K) retirement plans
- Educational assistance up to $2500 per year