Job Description
The Quality Assurance Clinical Analyst Level l plays a critical role in ensuring the accuracy, compliance, and efficiency of clinical review processes in a healthcare setting. This position is responsible for auditing case reviews and calls, verifying adherence to regulatory standards, and providing actionable feedback to enhance quality and operational effectiveness.
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 nursing or clinical license (or equivalent clinical certification preferred)
- Experience: Minimum of 2 years in clinical review or quality assurance within a healthcare or BPO setting. Demonstrates mastery of the processes and continue to serve as a subject matter expert.
- Regulatory Knowledge: Familiarity with HIPPA, 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.
Key Responsibilities
- Audit Clinical Reviews: Evaluate case reviews to ensure accuracy, completeness, and compliance with healthcare regulations, payer guidelines, and internal policies.
- Monitor Calls: Assess calls for adherence to clinical protocols, patient safety standards, and communication best practices.
- 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.
- May be assigned additional tasks as needed to support business operations and organizational objectives.
