Job Description
The Quality Assurance Clinical Analyst Level II is 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 unrestrictedPhilippine and USnursing or clinical license (or equivalent clinical certification preferred)
- Experience: Minimum of 3 years in clinical review,utilizationmanagementor quality assurance within a healthcare or BPO setting. Exhibits mastery inutilizationmanagement processes and guidelines.
- Regulatory Knowledge: Familiarity with HIPPA, NCQA, URAC, and other healthcare compliance standards.
- Technical Skills:Proficiencyin healthcare management systems, electronic medical records (EMR), and Microsoft Office applications
- Analytical Abilities: Strong attention to detail with the ability toidentifydiscrepancies 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,identifyinefficienciesand 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,regulationsand industry standards.
- IdentifyQuality 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,assistingin corrective actions and trainingobjectives.
- Collaborate with Cross-Functional Teams: Work closely with clinical reviewers, operations, and training teams to implement quality assurance strategies.
- Support Continuous Improvement:Participatein 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.
