The Clinical Quality Assurance Analyst is responsible for monitoring, auditing, and documenting clinical and non-clinical production quality in support of departmental goals and organizational standards. The role involves evaluating clinical documentation and decision-making, performing non-clinical audits, and collaborating with clinical and operational leadership to drive continuous improvement.
Requirements
- Audit clinical reviews and documentation, including medical necessity determinations, regulatory compliance, and adherence to medical policy
- Ensure adherence to clinical guidelines, payer policies, and industry standards (NCQA, URAC, CMS, state and federal regulations)
- Complete and document audits using standardized quality monitoring tools
- Maintain compliance with HIPAA and confidentiality requirements
- Support special audits, regulatory readiness activities, and ad hoc analysis requests
- Perform non-clinical audits as needed
- Participate in and support the design of quality monitoring forms and quality standards
- Record evaluations utilizing departmental quality monitoring forms
- Collect, evaluate, report on, and track operational data against performance metrics
- Prepare and analyze quality reports for management review
- Prepare and facilitate quality calibration sessions with designated department leads
- Facilitate meetings and prepare presentations related to insight analysis
- Monitor trends and provide input or feedback on the information reported on
- Identify, analyze, and share ways to optimize the quality monitoring process
- Complete all evaluations, reports, and employee coaching sessions on a timely basis
- Ability to learn new systems, tools, and methodologies as needed and continue progressing in a dynamic environment
- Support ad hoc quality monitoring, reporting, and analysis activities based on operational needs
- Work and communicate cross-departmentally
Benefits
- Competitive compensation and annual bonus program
- 401(k) retirement program with company match
- Company-paid life insurance
- Company-paid short term disability coverage (location restrictions may apply)
- Medical, Vision, and Dental benefits
- Paid Time Off (PTO)
- Paid Parental Leave
- Sick Time
- Paid company holidays and floating holidays
- Quarterly company-sponsored events
- Health and wellness programs
- Career development opportunities
