Manager, Clinical Quality Monitoring & Oversight (Healthcare)

Location: San Diego, California, United States; primarily on-site at the San Diego headquarters, with remote work possible only with management approval

Salary: $81,581–$138,690 annually

Company

hirify.global is a pharmacy benefit management company providing pharmaceutical and technology solutions for payers, providers, and consumers.

What you will do

• Lead clinical monitoring and oversight across prior authorization, appeals, delegated utilization management, and multiple lines of business.
• Direct retrospective case audits, targeted audits, delegation audits, corrective action plans, and inter-rater reliability testing.
• Prepare quality performance reports, trend analyses, audit findings, and recommendations for leadership, clients, governance committees, regulators, and accrediting bodies.
• Perform root cause analysis and implement operational improvements to strengthen clinical quality, efficiency, and regulatory compliance.
• Maintain clinical quality policies, monitoring methodologies, sampling standards, and audit scoring criteria.
• Manage, mentor, and develop clinical and non-clinical quality staff, including subordinate leaders and succession planning.

Requirements

• Pharm.D., B.S. in Pharmacy, BSN, or Associate Degree in Nursing with active, unencumbered pharmacist or registered nurse licensure in the state of residence.
• 5+ years of relevant experience, including one year as a subject matter expert and 3+ years of supervisory experience; four years of hirify.global experience may substitute for the supervisory requirement under the stated conditions.
• Required experience in managed care, pharmacy benefit management, or health plan quality management, utilization management, or accreditation.
• Experience with clinical prior authorization, Medicare Part D coverage determinations and redeterminations, quality audits, data analysis, and performance improvement.
• Strong leadership, communication, analytical, organizational, and problem-solving skills, including the ability to present findings to executives and external stakeholders.
• This position is not eligible for visa sponsorship.

Nice to have

• Experience with NCQA and/or URAC accreditation standards and State utilization review licensure requirements.
• Certified Professional in Healthcare Quality or an equivalent quality, compliance, or managed care certification.
• Experience with enterprise document management, prior authorization, appeals, and quality reporting systems.

Culture & Benefits

• Collaborative, performance-oriented environment focused on improving healthcare value and outcomes.
• Medical, dental, vision, and wellness programs.
• Paid time off, company-paid holidays, incentive compensation, and a 401(k) with company match.
• Life and disability insurance, tuition reimbursement, and employee referral bonus.
• Core business hours are typically Monday through Friday, 8:00 a.m. to 5:00 p.m.; additional hours may be required to meet business needs.