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CA, US

3 days ago Requisition ID: 2791

Job Description

The Quality Assurance Clinical Analyst Level IIIis responsible for ensuring accuracy, compliance, and efficiency of clinical review processes within a healthcare setting. This role involves conducting audits in a clinical set up, analyzing trends and implementing quality improvement initiatives to enhance operational effectiveness and regulatory adherence.

General Profile

• Education: Bachelor’s degree in Nursing, Physical Therapist, Healthcare Administration, or related field (or equivalent clinical certification preferred)
• Licensure: Holds an active and unrestricted Philippine and US nursing or clinical license (or equivalent clinical certification preferred)
• Experience: Minimum of 3 years in clinical review, utilization management or quality assurance within a healthcare or BPO setting. Exhibits mastery in utilization management processes and guidelines.
• Regulatory Knowledge: Familiarity with HIPPA, NCQA, URAC, and other healthcare compliance standards.
• Technical Skills: Proficiency in healthcare management systems, electronic medical records (EMR), and Microsoft Office applications
• Analytical Abilities: Strong attention to detail with the ability to identify discrepancies and recommend corrective actions.
• Communication Skills: Excellent verbal and written communications skills for delivering feedback and collaborating with Teams.
• Problem-Solving: Ability to assess complex cases, identify inefficiencies and propose solutions to enhance clinical review processes.
• Leadership Skill: Ability to mentor junior associates and contribute to quality assurance strategy development.

Key Responsibilities

• Audit Clinical Reviews: Conduct in-depth audits of case reviews and calls to ensure compliance with healthcare regulations, patient safety, internal policies, communication, and documentation accuracy.
• Ensure Regulatory Compliance: Verify that all clinical review processesare adhering to all laws, regulations and industry standards.
• Identify Quality Improvement Opportunities: Analyze trends, detect inconsistencies, and recommend process enhancements to improve efficiency and patient outcomes.
• Provide Constructive Feedback: Deliver detailed reports and insights to clinical teams, assisting in corrective actions and training objectives.
• Collaborate with Cross-Functional Teams: Work closely with clinical reviewers, operations, and training teams to implement quality assurance strategies.
• Support Continuous Improvement: Participate in the development and refinement of quality assurance frameworks, audit methodologies, and best practices.
• Maintain Documentation Standards: ensure proper record keeping of audit findings, compliance reports, and quality assessments for internal and external review.
• Stay updated on Industry trends: Keeps abreast of evolving healthcare regulations, and emerging best practices in clinical quality assurance.
• Utilize Quality Tools and Methodologies: Apply industry-standard quality assurance tools to enhance audit accuracy and process improvements.
• May be assigned additional tasks as needed to support business operations and organizational objectives.