Senior Manager, Medical Policy Quality Assurance and Rework Remediation

About the role

Policy coding and implementation errors can reach members and claims, so this role keeps those defects from spreading. Success means issues are found early, fixed at the root and documented well enough to pass an audit.

At a glance

What you will do

• Run the daily quality assurance work for medical policy coding and implementation.
• Take in, sort and assign defects, then track each one until closure is confirmed.
• Lead structured root cause analysis, including 5-Why sessions with business partners.
• Keep audit-ready records and report quality metrics and remediation results.

What they look for

• Experience managing quality assurance or remediation programs in a health plan setting.
• Working knowledge of medical policy, claims, configuration and payment integrity.
• Skill at running root cause analysis and corrective action plans to completion.

A typical week

• Review policy coding and workflow accuracy against quality standards.
• Meet clinical operations, configuration and compliance partners on open defects.
• Check corrective action plans and push aging or high-risk items to leadership.
• Pull trend data on defect patterns and update status reports.