Clinical Quality Manager, Medication Care

What you'll do

• Conduct investigations into Quality of Care (QoC) concerns by reviewing member complaints, provider documentation, and internal quality metrics to determine appropriate remediation or corrective actions in alignment with organizational policies and established quality frameworks.
• Exercise strong clinical judgment in determining provider interventions, escalations, and follow-up compliance monitoring, consulting with leadership for recommendations as appropriate.
• Partner with Medication Prescribers to obtain additional information, provide performance coaching, reinforce platform policies, procedures, and quality standards, and support ongoing quality improvement initiatives.
• Perform post-intervention compliance audits to evaluate provider improvement, identify persistent compliance gaps, and determine whether further escalation or corrective action is warranted.
• Analyze and report on quality trends, recurring performance concerns, and provider performance data to support continuous quality improvement initiatives and operational decision-making.
• Manage the annual peer review program for all Medication Prescribers, ensuring timely review completion, intervention tracking, provider follow-up, and compliance with organizational and regulatory standards.
• Maintain and optimize peer review tracking systems and documentation processes to monitor review completion, remediation activities, and quality outcomes.
• Partner with clinical leadership to operationalize peer review findings and facilitate provider performance improvement initiatives.
• Serve as a Medication Management quality subject matter expert and liaison for cross-functional initiatives involving clinical quality, provider operations, compliance, credentialing, and workflow optimization.
• Develop educational materials, slide decks, and supporting documentation required for Onboarding, Continuing Education, and other professional development activities for Medication Providers.
• Identify gaps in Medication Management policies and procedures and update/review policy manual to ensure alignment with clinical workflows, documentation standards, regulatory requirements, and organizational quality expectations.
• Collaborate with Legal/Compliance, Provider Operations, Clinical Operations, and other stakeholders on Quality of Care investigations, quality initiatives, operational projects, and systems development efforts.

What success looks like in this role

• Thoroughly and efficiently investigate complaints and grievances within specified SLAs
• Consistently make decisions about appropriate interventions for providers based on quality standards
• Deliver detailed guidance to providers to improve performance and ensure contract compliance
• Complete Medication Provider annual peer review on time and in accordance with process evaluation expectations
• Complete project-based work on time and at high quality

What you'll bring

• Behavioral Health Technician, Medical Assistant, LPN, RN, or similar direct care delivery role within the behavioral health field
• 3-5 years of experience in fast-paced direct healthcare, technology or clinical research environments
• Expertise in medical terminology, common medications, and conditions for behavioral health concerns
• Experience working directly with medical providers on delivering high quality care
• Outstanding written & verbal communication skills with collaborators and providers at all levels
• High level of attention to detail
• A thoughtful and collaborative approach to implementing continuous process improvement methodologies
• Ability to thrive in a fast-paced environment
• Humility, resourcefulness, empathy, professionalism
• Demonstrated passion for, and understanding of, mental health and the broader U.S. healthcare system
• Active LPN, RN, or NP license with a minimum of 3 years of clinical experience in behavioral health, psychiatric care, medication management, or related healthcare settings
• Experience supporting provider populations prescribing psychiatric medications
• Experience in behavioral health quality assurance, provider performance management, clinical operations, or healthcare quality improvement
• Strong knowledge of clinical documentation standards, provider quality oversight, and behavioral healthcare compliance requirements
• Strong organizational skills and attention to detail, with the ability to manage multiple concurrent workstreams and operational priorities
• Experience developing, maintaining, or improving operational workflows, reporting systems, dashboards, or quality tracking tools
• Strong written and verbal communication skills with the ability to engage providers and cross-functional stakeholders in a clear, professional, and constructive manner
• Experience developing provider-facing educational materials, onboarding resources, operational guidance, or training documentation
• Ability to thrive in a fast-paced and evolving environment with shifting priorities and operational ambiguity
• Collaborative, solutions-oriented, and operationally minded approach to problem solving
• Interest in leveraging AI-enabled tools, workflow automation, and systems improvements to improve quality operations and administrative efficiency

Nice to have

• Providing tele-behavioral health
• EAP experience
• Managing peer review initiatives
• Support for accreditation and regulatory bodies
• Works with ZenDesk, SalesForce or similar customer service platforms