Note: The job is a remote job and is open to candidates in USA. Community Health Plan of Washington seeks a Program Manager II to lead quality reporting, data governance, quality assurance, and regulatory reporting activities across healthcare quality programs. The role supports accurate, compliant, audit-ready submissions and drives cross-functional process improvement and quality performance.
Responsibilities
- Lead quality assurance and quality control processes supporting HEDIS, Prospective Medical Record Review (PMRR), CAHPS (Medicaid & Medicare), QHP, HOS and related quality measurement programs. Develop, implement and monitor quality controls that ensure data accuracy, regulatory compliance, audit readiness, and operational consistency across all quality activities. Partner with internal teams, third-party auditors, and vendors to ensure compliance, audit readiness, and successful program execution. Oversee resolution of audit findings, quality concerns and compliance risks
- Support the development, implementation, and continuous improvement of quality assurance and quality control frameworks, including validation methodologies, quality reviews, audit protocols, issue tracking, and corrective action plan processes. Monitor effectiveness of controls and provide recommendations to reduce risk and improve performance
- Lead quality validation activities to evaluate the accuracy, completeness, consistency, and reliability of regulatory reporting and performance measurement data. Conduct root-cause analysis of quality defects, reporting discrepancies, and audit findings. Partner with internal stakeholders and vendors to recommend corrective and preventive actions and strengthen data governance processes
- Coordinate audit readiness strategies, including mock audits, control testing, documentation reviews, quality monitoring activities, and remediation planning. Ensure organizational preparedness for NCQA, CMS, state, and external audit requirements
- Monitor vendor performance supporting HEDIS, CAHPS, HOS, PMRR, and other quality initiatives. Review performance metrics, assess compliance with contractual obligations, and provide recommendations for improvement strategies when performance gaps are identified
- Facilitate quality governance activities by supporting documentation standards, maintaining reporting controls, monitoring adherence to established policies and procedures, and communicating quality-related risks, findings and recommendations to leadership
- Develop and maintain detailed project plans including milestones, tasks, and target/actual dates of completion. Set SMART goals, allocate resources effectively, and ensure timely execution. Track team adherence to project timelines and clear barriers to team progress, including team conflict. Escalate risks and propose mitigation strategies to leadership
- Develop program knowledge to support key strategic opportunities and improvement strategies. Stay informed about industry trends, regulatory changes, and best practices. Use this knowledge to identify strategic opportunities and develop improvement strategies that align with organizational goals
- Maintain effective communication with stakeholders, ensuring regular updates on project status, issues, and recovery plans. Establish and nurture professional relationships with key partners to facilitate collaboration and support. Ensure all stakeholders are informed and engaged throughout the project lifecycle
Skills
- Bachelor's degree in Business Administration, Health Information Management, Healthcare Administration, Analytics, or other relevant academic field, or an equivalent combination of education and/or highly relevant experience
- 3+ years' experience in program management, preferably related to HEDIS, CMS Star, Value Based Payment Programs, Risk Adjustment, or general healthcare (required)
- Proficient in Microsoft Office Suite (Word, Excel, Outlook, and PowerPoint), including advanced Excel functionality. Experience utilizing SharePoint, Confluence, JIRA, or Smartsheet to support project management, workflow tracking, documentation, issue management, operational planning, and cross-functional collaboration (required)
- Knowledge of Medicaid, Medicare and/or Exchange principles and practices pertaining to any of the following: Centers for Medicaid and Medicare (CMS), National Committee for Quality Assurance (NCQA), Pharmacy Quality Alliance (PQA), Milliman and/or Acumen with emphasis in quality improvement
- Strong analytical skills and ability to interpret data identify key trends, summarize, and communicate information in a concise and understandable manner
- Strong vendor management, objective targeting, and service level agreement monitoring
- Knowledge of and experience leveraging change management principles, practices, and methodologies
- Skilled in adapting to dynamic environments and juggling multiple tasks and projects to meet operational demands driven by business needs
- Ability to work both independently without supervision and collaboratively as part of a team
- Ability to work with a high degree of accuracy and meet established deadlines
- Maintain strong organizational skills to ensure efficient and effective operations
- Strong skills in presenting complex data, reports, and training to groups
- PMP, Agile Professional, or other formal project management certification (preferred)
- Experience in program development, product development, process improvement, and evaluation is strongly preferred
- Working knowledge of SQL and/or Snowflake data environments, including the ability to query and validate data, support reporting activities, investigate data quality issues, and partner effectively with analytics, engineering and technical teams (preferred)
- Have experience with Community Health Centers (CHC), Federally Qualified Health Centers (FQHC), or other healthcare systems focused on those with low income and/or barriers to equitable healthcare (preferred)
Benefits
- 10% annual incentive target based on company, department, and individual performance goals
- Medical, Prescription, Dental, and Vision
- Telehealth app
- Flexible Spending Accounts, Health Savings Accounts
- Basic Life AD&D, Short and Long-Term Disability
- Voluntary Life, Critical Care, and Long-Term Care Insurance
- 401(k) Retirement and generous employer match
- Employee Assistance Program and Mental Fitness app
- Financial Coaching, Identity Theft Protection
- Time off including PTO accrual starting at 17 days per year
- 40 hours Community Service volunteer time
- 10 standard holidays, 2 floating holidays
- Compassion time off, jury duty
- Remote work
Company Overview
Company H1B Sponsorship