Senior Manager Medical Policy QA & Rework Remediation

Sr. Manager, Medical Policy Quality Assurance (QA) & Rework Remediation is responsible for managing the day-to-day operations of the Medical Policy quality assurance and remediation program. This role oversees quality reviews, issue intake, defect investigation, root cause analysis, corrective action implementation, remediation tracking, and closure validation activities to ensure the accuracy and integrity of Medical Policy implementation and policy coding.

The Manager works collaboratively with Medical Policy, Clinical Operations, Configuration, Claims, Payment Integrity, Informatics, Compliance, Appeals, and Operational business partners to identify, investigate, remediate, and monitor policy-related defects and quality concerns. The role is accountable for maintaining audit-ready documentation, supporting governance processes, monitoring defect trends, and ensuring remediation activities are completed timely and effectively.

This position serves as the operational leader responsible for executing the Medical Policy QA and remediation workflow and ensuring identified issues are addressed through sustainable corrective and preventive actions.

Quality Assurance Management

• Manage the day-to-day execution of Medical Policy quality assurance activities.
• Oversee ongoing reviews of policy coding, implementation accuracy, operational workflows, and policy-related processes.
• Monitor quality trends and identify emerging defect patterns or operational risks.
• Ensure quality review methodologies and documentation standards are consistently applied.
• Track and report quality performance metrics and remediation outcomes.
• Support process improvement activities based on quality findings and trend analysis.

Rework Remediation Oversight

• Manage the intake, triage, prioritization, assignment, and tracking of Medical Policy defects and quality concerns.
• Ensure suspected issues are appropriately researched and validated prior to defect confirmation.
• Oversee remediation activities from issue identification through closure validation.
• Monitor corrective action plans and ensure assigned owners complete required remediation activities within established timeframes.
• Escalate aging, high-risk, or unresolved issues to leadership for review.
• Validate that remediation efforts adequately address identified root causes.

Root Cause Analysis & Corrective Actions

• Facilitate structured root cause analysis activities using standardized methodologies, including 5-Why and other problem-solving techniques.
• Partner with operational and business stakeholders to identify contributing factors and potential corrective actions.
• Ensure root cause findings are documented and supported by appropriate evidence.
• Track implementation of corrective and preventive actions.
• Monitor effectiveness of implemented solutions to reduce recurrence of issues.
• Identify opportunities for process improvements that improve quality and reduce rework.

Operational Governance Support

• Support Medical Policy governance processes through tracking, reporting, and issue management activities.
• Prepare status reports, dashboards, and remediation summaries for leadership review.
• Maintain documentation supporting remediation activities, corrective actions, and closure validation.
• Participate in governance forums, operational reviews, and quality discussions.
• Ensure remediation activities follow established policies, procedures, and compliance requirement