Manager, Quality and Risk
Position Summary The Manager of Quality & Risk is responsible for overseeing clinical quality, patient safety, and regulatory risk management across telehealth and care management programs. This role ensures clinical services are delivered in compliance with CMS, payer, and organizational standards while proactively identifying, mitigating, and monitoring clinical, operational, and regulatory risk. The Manager partners closely with clinical leadership, operations, compliance, and analytics teams to support high-quality, safe, and audit-ready care delivery. Core Responsibilities Clinical Quality Oversight
- Lead quality assurance activities across care management programs and pilots (CCM, PCM, RPM, CoCM, RTM, Heart Failure).
- Develop, maintain, and monitor quality metrics, KPIs, and outcome measures.
- Conduct routine chart audits and documentation reviews to ensure clinical accuracy, completeness, and compliance.
- Identify trends in quality gaps, adverse events, and near misses; recommend corrective actions.
- Support continuous quality improvement (CQI) initiatives and performance improvement plans.
Risk Management & Patient Safety
- Identify, assess, and mitigate clinical and operational risks related to patient safety, escalation, and care delivery.
- Develop and oversee incident reporting, investigation, root cause analysis, and follow-up.
- Develop and oversee patient complaint management system, investigation, root cause analysis, and follow-up.
- Ensure timely escalation of high-risk clinical scenarios in alignment with organizational protocols.
- Collaborate with leadership to implement risk mitigation strategies and monitor effectiveness.
Regulatory & Compliance Support
- Ensure clinical workflows and documentation align with CMS requirements, payer policies, and applicable regulations.
- Support audit preparedness and response, including internal audits and external reviews.
- Partner with Compliance and Legal teams on policy development, updates, and staff education.
- Monitor regulatory changes and assess impact on clinical operations and risk exposure.
Education & Clinical Governance
- Develop and deliver education related to quality standards, risk management, and best practices.
- Support onboarding and ongoing training for clinical staff related to documentation, escalation, and safety.
- Participate in clinical governance committees and contribute to protocol development and updates.
Data & Reporting
- Analyze quality and risk data to identify trends, opportunities, and emerging risks.
- Prepare quality and risk reports for clinical leadership and executive review.
- Collaborate with analytics teams to ensure accurate data capture and meaningful reporting.
Scope of Role
- Serves as a second-line oversight role, supporting supervisors and managers.
- Does not provide direct patient care.
- Acts as a key liaison between clinical operations, compliance, and leadership.
Required Qualifications
- Active RN license or comparable credentials
- Bachelor’s degree required; Master’s degree in nursing, public health, healthcare administration, or related field preferred.
- 5+ years of clinical experience, including care management or telehealth environments.
- Demonstrated experience in quality assurance, risk management, or compliance.
- Strong knowledge of CMS care management programs and documentation requirements.
- Experience with chart auditing and quality improvement methodologies.
Preferred Qualifications
- Experience supporting CCM, CoCM, RPM, PCM, or RTM programs.
- Familiarity with value-based care and population health models.
- Experience in telehealth or remote clinical operations.
- Certification in Quality, Risk Management, or Patient Safety (e.g., CPHQ, CPPS) a plus.
Key Competencies
- Clinical judgment and risk assessment
- Regulatory and compliance literacy
- Data-driven decision making
- Strong communication and collaboration skills
- Attention to detail and audit readiness
- Ability to influence without direct authority
Work Environment
- Remote / telehealth-based role.
- Standard business hours with flexibility for incident response as needed.
- Collaborative, cross-functional environment.
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