Manager – Quality & Acc.

WNS

. Lead the Quality Management Program, including annual program evaluation, quality improvement initiatives, KPI development, performance monitoring, and continuous process improvements .

Posted 10/27/2026full-timeRemote • Texas • United StatesMid-LevelSenior💰 $100,000 - $125,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Quality Management, Compliance, and Utilization Management, with a strong focus on developing KPIs, conducting root cause analyses, and leading quality improvement initiatives. Proven ability to oversee accreditation activities and ensure adherence to regulatory standards while providing leadership and support to teams.

Highest-signal resume keywords

Utilization Management ExperienceQuality Management ExperienceLeadership in Managed CareURAC and NCQA Accreditation KnowledgeKPI Development and Performance Improvement

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Quality Improvement InitiativesKPI DevelopmentRoot Cause AnalysisQuality Audit ProgramsData Integrity AuditsAccreditation Standards InterpretationCorrective Action PlanningRegulatory CompliancePerformance MonitoringClinical Review Activities

Soft Skills

LeadershipCommunicationCritical ThinkingOrganizational SkillsCollaboration

Certifications & Qualifications

Active RN LicenseCPHQ CertificationLean Six Sigma Training

Industry Keywords

Utilization ManagementManaged CareMedicare RegulationsMedicaid RegulationsAccreditation SurveysQuality Management ProgramCompliance StandardsAudit ProgramsClient AuditsFraud Reporting

About the role

Key responsibilities & impact

Lead the Quality Management Program, including annual program evaluation, quality improvement initiatives, KPI development, performance monitoring, and continuous process improvements
Identify compliance, accreditation, contractual, and operational risks; conduct root cause analyses; develop corrective action plans; monitor intervention effectiveness; and escalate significant issues
Develop, implement, and oversee quality audit programs for clinical and physician review activities, including IRR audits, adverse determination reviews, and data integrity audits
Ensure audit findings are accurate, consistent, defensible, and supported by standardized methodologies, sampling techniques, and regulatory requirements
Maintain expertise in utilization management workflows, policies, and operational processes for oversight and auditing
Partner with operations, clinical leadership, compliance, education, IT, and other stakeholders to resolve deficiencies and sustain corrective actions
Maintain readiness for accreditation surveys, client audits, and regulatory reviews by monitoring requirements, updating policies and audit criteria, maintaining evidence repositories, and coordinating survey activities
Oversee URAC and NCQA accreditation activities, including standards interpretation, gap assessments, survey preparation, application management, and response coordination
Lead preparation for external audits, surveys, and delegated oversight reviews
Lead Quality Management and Compliance Committees and provide governance, oversight, reporting, and recommendations to organizational leadership
Maintain Quality Management Program documentation, including program descriptions, work plans, annual evaluations, committee records, quality improvement projects, and required reports
Analyze and present quality, compliance, accreditation, complaint, utilization management, and audit data to leadership, committees, clients, and external stakeholders
Oversee complaint investigations, trend analysis, reporting, and corrective actions
Oversee fraud, waste, and abuse reporting activities and related documentation
Oversee regulatory and accreditation-required education tracking, exclusion monitoring, clinician credentialing, licensure verification, and credentialing record maintenance
Provide leadership, coaching, performance management, workload balancing, succession planning, and professional development for Quality team members
Ensure compliance with federal and state regulations, accreditation standards, company policies, privacy requirements, and professional standards
Provide exceptional service to internal and external stakeholders and perform other assigned duties

Requirements

What you’ll need

Graduate of an accredited nursing program
Active, unrestricted RN license required
5+ years of utilization management experience in a health plan, UM vendor, or delegated UM organization, including prior authorization
3+ years of quality, audit, compliance, accreditation, or quality management experience, including audit programs, KPI reporting, and corrective action planning
2+ years of progressive leadership experience in a managed care environment with responsibility for staff performance and team outcomes
Demonstrated success developing KPIs, conducting root cause analyses, and driving measurable performance improvement
Working knowledge of URAC and/or NCQA accreditation standards and quality management program requirements
Knowledge of Medicare, Medicaid, and commercial utilization management regulations, including CMS and state utilization review requirements
Experience leading quality, productivity, and performance improvement initiatives
Strong leadership, facilitation, communication, critical thinking, and organizational skills
Ability to thrive in a fast-paced, evolving environment and collaborate effectively across teams
HIPAA-compliant remote location with reliable high-speed internet
Ability to use the telephone, sit, enter data, and view a PC screen for up to 8 hours
Ability to prioritize in a multi-task environment
BSN, MSN, or other bachelor's degree preferred
Participation in accreditation surveys or delegation audits preferred
Prior quality management experience within a health plan or delegated utilization management organization strongly preferred
CPHQ certification preferred; Lean Six Sigma or other process improvement training is a plus

Benefits

Comp & perks

Medical, dental, and vision insurance
Paid time off (PTO), holidays, and sick leave
401(k) with company match or other retirement plan
Life and AD&D Insurance
Employee Assistance Program
Performance-based bonuses, incentive pay, or commissions may be available
Reasonable accommodations for individuals with disabilities and sincerely held religious beliefs