The Role
Leads quality assurance, clinical quality monitoring, regulatory compliance, audit readiness, performance governance, and process improvement across healthcare operations. Oversees quality metrics, dashboards, corrective action plans, accreditation requirements, and client reporting. Manages quality leaders and auditors, develops staff capabilities, and drives Lean Six Sigma, Kaizen, standardization, and continuous improvement initiatives supporting utilization management, care management, prior authorization, appeals, and grievances.
Summary Generated by Built In
Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. The company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics. Sagility has more than 25,000 employees across 5 countries.
Job title:
Job Description:
Preferred Qualifications
- Registered Nurse (RN) preferred.
- Experience supporting healthcare payer operations, utilization management, care management, prior authorization, or appeals and grievances.
- Experience with NCQA, CMS, URAC, or other healthcare accreditation and regulatory standards.
- Leads the development, implementation, and governance of quality assurance and quality management programs across Clinical operations.
- Ensures objective and consistent monitoring of all customer and member interaction channels, including web, voice, email, chat, correspondence, and clinical case reviews.
- Establishes and monitors quality performance metrics, scorecards, and dashboards, identifying trends, opportunities, and risks through data-driven analysis.
- Provides actionable insights and quantifiable data to support quality evaluations, operational decision-making, and client reporting.
- Partners with Operations, Training, Workforce Management, Clinical Leaders, Medical Directors, and Support Functions to drive sustainable quality improvements and operational excellence.
- Oversees clinical quality monitoring activities, including utilization management (UM), care management (CM), prior authorization, appeals, grievances, and other healthcare operations, ensuring adherence to client, regulatory, and accreditation requirements.
- Ensures compliance with NCQA, CMS, URAC, state, federal, and client-specific standards through robust audit and monitoring programs.
- Conducts quality governance reviews, identifies emerging risks, develops corrective action plans, and tracks remediation efforts to closure.
- Acts as the primary quality liaison for clients and business partners, providing quality oversight, audit support, regulatory readiness, and resolution of quality-related concerns.
- Reviews and approves quality control documentation, standard operating procedures, audit tools, and process changes prior to implementation.
- Drives continuous process optimization through Lean, Six Sigma, Kaizen, and business transformation initiatives.
- Supports inter-rater reliability (IRR) programs, calibration activities, and auditor quality assurance to ensure consistency and accuracy of evaluations.
- Promotes member-centric quality outcomes through improved accuracy, compliance, turnaround time, service quality, and customer experience measures.
- Leads, mentors, and develops Quality Managers/Asst Managers, Quality Team Leads and auditors to achieve operational and quality objectives.
- Builds a high-performing quality culture through coaching, performance management, succession planning, and leadership development.
- Effectively manages organizational change, resolving resistance and aligning teams toward strategic quality initiatives.
- Conducts regular quality reviews, team meetings, calibration sessions, and knowledge-sharing forums to drive consistency and engagement.
- Provides subject matter expertise and coaching on healthcare quality standards, clinical audits, regulatory requirements, Lean, Six Sigma, and continuous improvement methodologies.
- Leads recruitment, onboarding, and capability development for quality and clinical quality resources.
- Conducts performance evaluations and career development planning for direct reports.
- Reviews employee relations concerns and disciplinary actions in accordance with company policies and procedures.
- Develops and facilitates training programs related to quality management systems, clinical auditing methodologies, quality tools, process excellence, and regulatory requirements.
- Serves as mentor and sponsor for Lean Six Sigma Green Belt, Black Belt, Kaizen, and Process Capability Studies (PCS) projects.
- Collaborates with operations and clinical leadership teams to improve quality competencies, clinical judgment consistency, and audit effectiveness.
- Leads strategic quality improvement initiatives focused on operational excellence, clinical accuracy, compliance, efficiency, and member outcomes.
- Identifies opportunities through audits, root cause analysis, customer feedback, Voice of Customer (VOC), complaints, appeals, and quality monitoring programs.
- Develops and implements corrective and preventive action plans (CAPA) to address performance gaps and reduce operational risk.
- Drives process redesign, automation opportunities, standardization efforts, and best-practice adoption across healthcare operations.
- Establishes process health indicators, quality scorecards, and governance mechanisms to sustain improvement efforts.
- Partners with clients and operational leaders to improve contractual performance metrics, quality outcomes, regulatory compliance, and customer experience measures.
- Utilizes data analytics and process improvement methodologies to identify systemic issues and achieve measurable business impact.
- Oversees clinical quality audit programs, ensuring accuracy, consistency, and compliance of clinical decision-making and documentation.
- Supports readiness for client audits, accreditation reviews, and regulatory examinations.
- Evaluates compliance with clinical policies, medical necessity criteria, care management standards, and utilization management guidelines.
- Monitors quality indicators including accuracy, compliance, inter-rater reliability, turnaround time, first-pass quality, member satisfaction, and audit findings.
- Partners with Clinical Operations, Medical Directors, and Compliance teams to address clinical quality risks and implement remediation strategies.
- Ensures continuous alignment with evolving healthcare regulations, accreditation standards, and industry best practices.
- Protects organizational assets by complying with the principles of the Quality and Information Security Management System (QISMS).
- Ensures the confidentiality, integrity, and availability of information in accordance with organizational, client, regulatory, and healthcare privacy requirements.
- Promotes compliance with HIPAA, data privacy regulations, information security policies, and business continuity requirements.
- Supports risk management initiatives and fosters a culture of quality, compliance, security, and accountability.
Location:
Skills Required
- Registered Nurse (RN)
- Experience supporting healthcare payer operations, utilization management, care management, prior authorization, or appeals and grievances
- Experience with NCQA, CMS, URAC, or other healthcare accreditation and regulatory standards
Sagility Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about Sagility and has not been reviewed or approved by Sagility.
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Healthcare Strength — The company provides medical, dental, and vision coverage along with life insurance, short- and long-term disability, Flexible Spending Accounts, and an Employee Assistance Program. Policies also indicate coverage for dependents according to local regulations and include wellness and mental health initiatives.
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Retirement Support — A 401(k) with employer contribution is part of the standard package. Role descriptions and materials consistently reference retirement plan access alongside other core benefits.
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Leave & Time Off Breadth — Paid time off is provided, and formal leave types include maternity, paternity, adoption, and bereavement in line with local regulations. Additional flexibility elements such as hybrid or work-from-home arrangements are noted in some contexts.
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The Company
What We Do
Sagility is a U.S.-based, tech-enabled healthcare business process management company that supports payers, providers, and their partners to deliver best-in-class operations, enhance the member and provider experience, improve the quality of care and promote health equity all while delivering cost-effective healthcare financial and clinical outcomes. Sagility Technologies uses a holistic consulting approach to identify the root causes of healthcare payer and provider pain points, analyze the issues, and provide a complete solution that encompasses people, process, and technology platform improvements. Equipped with a strategic solutions mindset, our core focus is on what most benefits the client. Combining healthcare operations and technology experience with advanced UI, UX, and analytics expertise, we develop and deploy customized solutions for our client’s business. Additionally, with our extensive global resources and facilities, we provide the best service/price ratio for any service outsourcing needs.
