临床质量资深经理（远程工作，任何城市，佛罗里达州）

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.

Summary

We are seeking a talented individual for an Associate Manager, Clinical Quality who is responsible for supervising Quality Assurance activities for Prior Authorization reviews. The Associate Manager, Clinical Quality plays an integral role in ensuring the accuracy, consistency, timeliness, and regulatory compliance of clinical review and authorization decisions. This role leads a team of clinical quality auditors and reviewers, monitors adherence to clinical criteria and contractual requirements, evaluates interrater reliability, identifies trends, and drives improvement initiatives that support appropriate, evidence-based determinations and a positive provider and member experience. The Associate Manager oversees daily team operations by assigning work, monitoring productivity and quality performance, and analyzing workflows to improve efficiency and outcomes. This leader consistently demonstrates effective change management by communicating changes clearly and timely, building commitment, supporting those affected by change, monitoring implementation, and evaluating results.

Your role in our mission

• Supervise the Prior Authorization quality review program, including policies, procedures, and controls supporting compliance with standards, regulations, accreditation requirements, and contracts.

• Develop and maintain quality assurance processes, audit methodologies, and performance benchmarks for medical and behavioral health Prior Authorization reviews.

• Supervise and mentor clinical quality auditors and reviewers through education, coaching, and performance feedback.Monitor and report quality, accuracy, timeliness, productivity, denial rationale, and interrater reliability metrics.

• Identify trends, root causes, and improvement opportunities in clinical criteria application, documentation, review consistency, and workflows.

• Analyze audit results, appeals, complaints, and regulatory findings to identify issues and recommend corrective actions.

• Prepare reports and dashboards for leadership on performance, audit outcomes, risks, and improvement initiatives.

• Ensure Prior Authorization reviews are completed accurately, consistently, and within required timeframes.

• Develop and deliver training based on audit findings, policy updates, and performance trends.

• Maintain knowledge of CMS, Medicaid, accreditation standards, clinical policies, and industry practices.

• Lead quality improvement initiatives that enhance accuracy, consistency, efficiency, and experience.

• Serve as a subject matter expert for new tools, automation, operational readiness, and escalated quality issues.

• Manage individual and team performance to meet or exceed performance standards.

• Perform other duties as assigned.

What we're looking for

• Associate degree required; bachelor’s degree preferred.

• Current, unrestricted RN license required; additional utilization management, case management, or healthcare quality certification preferred.

• Working knowledge of Prior Authorization, utilization management, medical necessity review, adverse determination processes, and applicable regulatory and accreditation requirements.

• Demonstrated ability to apply evidence-based clinical criteria, health plan policies, benefit requirements, and clinical judgment consistently and accurately.

• Minimum 5 years of experience in Prior Authorization, utilization management, clinical review, or healthcare quality assurance.

• Minimum 2 years of leadership or quality assurance experience in a health plan, managed care, utilization management, or healthcare setting.

• Strong analytical, communication, coaching, and problem-solving skills, with experience using quality data to drive measurable improvement.

What you should expect in this role

• Remote- U.S.

• Up to 20% Travel

Will accept applications until October 30, 2026.

The pay range for this position is $71,500.00 - $102,100.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.
We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.
Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Gainwell Technologies defines “wages” and “wage rates” to include “all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.
Originally posted on Himalayas