About Pacific Health Group
Pacific Health Group (PHG) is committed to improving health outcomes by addressing the medical, behavioral, and social needs of the communities we serve. Through programs such as Enhanced Care Management (ECM), Community Supports (CS), Community Health Worker (CHW) services, Behavioral Health, and other community-based healthcare programs, PHG works collaboratively with health plans, providers, community organizations, and other partners to support whole-person care.Our work is grounded in accountability, collaboration, innovation,
integrity, and a commitment to improving access to high-quality services for vulnerable and underserved populations.
Position Summary
The Quality Assurance (QA) Manager is responsible for the leadership, development, implementation, oversight, and continuous improvement of Pacific Health Group's organization-wide Quality Assurance program.
This position provides quality oversight across PHG programs and operational departments, including Enhanced Care Management (ECM), Community Supports (CS), Community Health Worker (CHW) services, Behavioral Health, Revenue Cycle, Outreach, and other organizational functions as assigned.
The QA Manager ensures that services, documentation, workflows, and operational practices align with applicable health plan requirements, contractual obligations, regulatory standards, internal policies and procedures, and established PHG quality expectations.
The QA Manager leads routine and targeted audits, develops quality metrics and dashboards, identifies trends and systemic risks, oversees corrective action follow-up, strengthens operational workflows, and works collaboratively with department managers to improve quality, accuracy, consistency, and adherence to applicable requirements.
This position provides direct leadership and oversight to assigned Quality Assurance personnel and serves as a key quality resource to the Directors of Community Health & Operations and departmental leadership.
The QA Manager is expected to operate proactively and independently within the scope of the position. Quality concerns should be identified through established monitoring and auditing processes rather than solely through leadership escalation.
Essential Duties and Responsibilities
Quality Assurance Program Management
Develop, implement, manage, and continuously improve PHG's organization-wide Quality Assurance program.
Establish standardized quality expectations, audit methodologies, monitoring processes, scoring criteria, and reporting requirements.
Develop annual and ongoing quality monitoring plans based on organizational priorities, payer requirements, identified risks, audit findings, and performance trends.
Ensure quality processes are consistently applied across applicable programs and departments.
Establish clear standards for documentation quality, workflow adherence, operational accuracy, timeliness, and applicable quality requirements.
Evaluate existing workflows and recommend improvements designed to reduce errors, strengthen accountability, and improve service delivery.
Maintain Quality Assurance policies, procedures, audit tools, checklists, workflows, and standard operating procedures.
Ensure QA processes evolve as payer, contractual, regulatory, program, and organizational requirements change.
Establish risk-based monitoring strategies that prioritize high-risk programs, requirements, workflows, or identified areas of concern.
Health Plan, County & External Audit Readiness
Maintain organizational readiness for health plan audits, county reviews, monitoring activities, program reviews, and other external quality assessments within QA's scope.
Coordinate preparation for external audits and reviews.
Review applicable documentation and records in advance of scheduled audits when appropriate.
Coordinate with department leadership to ensure required materials are accurate, complete, organized, and available.
Maintain centralized tracking of upcoming audits, requested documentation, submission deadlines, findings, and required responses.
Track external audit findings and required corrective actions.
Support development and coordination of responses to health plan, county, or external quality findings.
Monitor completion of remediation activities following external reviews.
Maintain organized records of audit requests, submissions, findings, responses, corrective actions, and supporting documentation.
Identify trends across external reviews and recommend organization-wide improvements when appropriate.
Promptly communicate significant audit findings or risks to the Directors of Community Health & Operations.
Documentation & Program Quality
Maintain working knowledge of documentation and quality requirements applicable to PHG's contracted programs and services.
Monitor adherence to established documentation timelines and quality standards.
Evaluate whether documentation appropriately reflects services provided and established program requirements.
Identify documentation trends that may affect reimbursement, contractual performance, audit outcomes, member services, or quality of service.
Collaborate with program leadership to correct documentation deficiencies and strengthen workflows.
Communicate significant changes in quality or documentation requirements to affected departments.
Develop standardized tools, checklists, and guidance to promote consistent documentation practices.
Partner with Revenue Cycle when documentation deficiencies may affect billing or reimbursement while maintaining clear departmental ownership of Revenue Cycle functions.
Quality Team Leadership & Performance Management
Provide direct supervision, leadership, coaching, and support to assigned Quality Assurance personnel.
Establish clear individual and departmental performance expectations and KPIs.
Assign and monitor audit responsibilities, workloads, priorities, and deadlines.
Conduct regular one-on-one meetings and QA team meetings.
Monitor staff productivity, audit accuracy, consistency, timeliness, and completion of assigned responsibilities.
Conduct performance evaluations and provide ongoing coaching and professional development.
Address performance deficiencies promptly and partner with Human Resources when appropriate.
Evaluate staffing levels and workload distribution based on organizational quality monitoring needs.
Ensure appropriate coverage and continuity of QA responsibilities during staff absences.
Develop QA staff competency in auditing, documentation review, quality standards, data analysis, root-cause analysis, and effective communication.
Foster a culture of objectivity, accountability, professionalism, consistency, collaboration, and continuous improvement.
Audit Consistency & Calibration
Establish standardized auditing methodologies and scoring expectations across the QA department.
Conduct routine calibration sessions with QA personnel to promote consistent interpretation and application of audit standards.
Monitor consistency between QA reviewers and identify areas requiring clarification or retraining.
Develop standardized audit guidance and reference materials.
Periodically review completed QA audits for accuracy and consistency.
Address significant variations in scoring or interpretation.
Update audit tools and guidance when requirements change or inconsistencies are identified.
Manager Coaching & Departmental Accountability
Provide clear, objective, and actionable feedback to department managers based on audit findings and quality trends.
Support department managers in understanding quality expectations and identified areas requiring improvement.
Assist managers in developing practical corrective strategies within their departments.
Provide quality data that enables managers to hold their teams accountable for documentation, workflow, and performance expectations.
Monitor whether departmental corrective actions result in measurable improvement.
Escalate recurring or unresolved deficiencies through the appropriate leadership structure.
Maintain appropriate boundaries between QA oversight and department management responsibilities.
Department managers remain responsible for the day-to-day performance, supervision, corrective action, and operational management of their teams. Quality Assurance is responsible for identifying, documenting, communicating, monitoring, and escalating quality concerns within its scope.
Training & Quality Education
Identify training needs based on audit results, quality trends, payer changes, contractual requirements, and recurring deficiencies.
Develop and deliver training regarding documentation standards, quality requirements, audit expectations, payer updates, and operational workflows.
Partner with Learning & Development and department leadership to incorporate quality expectations into onboarding and ongoing employee training.
Develop reference materials, job aids, audit guides, checklists, and other quality resources.
Conduct calibration and educational sessions as needed.
Evaluate whether training interventions result in measurable improvements in quality performance.
Recommend retraining or additional intervention when quality deficiencies continue following education.
Data Management, Analytics & Reporting
Develop and maintain organization-wide quality dashboards, scorecards, reports, and tracking systems.
Ensure quality data is accurate, current, actionable, and presented in a manner that supports leadership decision-making.
Validate underlying QA data before presenting organizational quality results to leadership.
Analyze audit results to identify trends, patterns, recurring deficiencies, and root causes.
Track performance by department, program, team, payer, audit category, and other relevant measures.
Provide routine quality performance reports to the Directors of Community Health & Operations.
Provide timely escalation reports when significant quality concerns are identified.
Track the effectiveness of corrective action plans and continuous improvement initiatives.
Partner with Information Technology to ensure systems, templates, workflows, reports and data fields support accurate quality monitoring.
Identify inconsistencies or limitations in available data and communicate them when reporting quality results.
Cross-Functional Collaboration & Continuous Improvement
Work closely with department managers and organizational leadership to improve processes, reduce errors, and strengthen quality.
Participate in cross-departmental meetings, committees, and strategic initiatives as appropriate.
Support organizational readiness for new programs, payer requirements, contractual changes, and policy updates.
Identify opportunities to standardize processes across departments when appropriate.
Conduct root-cause analysis when systemic quality issues are identified.
Develop recommendations based on quality data and measurable trends.
Partner with Operations, Revenue Cycle, Finance, Information Technology, Human
Resources, Learning & Development, and program leadership as appropriate to address cross-functional quality issues.
Support implementation and monitoring of approved process improvements.
Strengthen PHG's overall culture of accountability, accuracy, quality, and service excellence.
New Program & Operational Readiness
Participate in quality-readiness planning for new health plans, counties, programs, services, or significant operational changes.
Review applicable quality, documentation, service-delivery, authorization, encounter, and reporting requirements prior to implementation.
Ensure appropriate QA audit tools and monitoring processes are developed before or shortly following implementation.
Partner with department leadership and Learning & Development to identify training needs related to new requirements.
Conduct post-implementation monitoring to identify early quality concerns.
Report significant readiness gaps or implementation risks to the Directors of Community Health & Operations.
Key Performance Indicators (KPIs)
The Quality Assurance Manager is responsible for establishing, monitoring, reporting, and improving quality performance. Key performance indicators may include:
- Documentation accuracy and completeness.
- Documentation timeliness.
- Assessment and reassessment completion and timeliness.
- Care plan completion and timeliness.
- Required signature completion.
- Workflow adherence.
- Audit completion rate.
- Audit accuracy and consistency.
- QA staff productivity.
- Corrective Action Plan completion rate.
- Timeliness of corrective action resolution.
- Percentage of overdue corrective actions.
- Repeat deficiency rate.
- Departmental and program quality scores.
- Health plan and county audit findings.
- External audit readiness.
- Reduction in recurring documentation deficiencies.
- Training effectiveness following identified quality concerns.
- Timeliness and accuracy of QA reporting.
- Quality improvement initiative completion.
- Sustained improvement following corrective actions.
- Implementation of new or revised payer requirements.
- Timeliness of escalation of high-risk findings.
- Performance metrics and departmental targets may be modified based on organizational priorities, contractual obligations, payer requirements, program standards, and identified quality risks.
- Quality Reporting Expectations
- The QA Manager is expected to provide the Directors of Community Health & Operations with consistent visibility into organizational quality performance.
- Routine reporting should include, as applicable: Overall organizational quality performance.
- Department and program quality scores.
- Audit completion status.
- Documentation quality and timeliness trends.
- Assessment, reassessment, and care plan trends.
- Outstanding Corrective Action Plans.
- Overdue corrective actions.
- Repeat findings.
- High-risk or systemic quality concerns.
- Health plan and county audit activity and findings.
- Emerging payer or contractual requirements affecting quality monitoring.
- Training needs identified through QA reviews.
- Quality improvement initiatives.
- Areas demonstrating sustained improvement.
- Areas requiring leadership intervention.
- Significant quality concerns, systemic failures, recurring deficiencies, or risks that could materially affect PHG's contractual performance, reimbursement, member services, audit performance, or organizational operations must be promptly escalated to the Directors of Community Health & Operations.
- Leadership & Accountability Expectations
- The Quality Assurance Manager is expected to serve as the accountable leader for the Quality
The QA Manager is not expected to assume responsibility for managing another department's employees or day-to-day operations. Department managers remain responsible for the performance and operational management of their teams.
The QA Manager is responsible for identifying, documenting, communicating, tracking, validating, and escalating quality concerns through the appropriate leadership structure.
