Perform in-depth audits of clinical reviews and calls to ensure regulatory compliance and documentation accuracy; analyze trends to recommend quality improvements; provide feedback and training, mentor junior staff, collaborate with cross-functional teams, maintain audit records, and support continuous improvement of clinical review processes.
Job Description
The Quality Assurance Clinical Analyst Level III 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 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 processes are 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.
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