Senior Clinical Analyst

About the Role

As a Sr. Clinical Analyst, you will review complex medical records and hospital-based clinical scenarios to provide expert medical determinations on requested services.

You will work closely with nursing and clinical teams while supporting utilization review and other clinical functions. With experience, you may also take on responsibilities as a subject matter expert, trainer, or auditor.

Key Responsibilities

• Review and evaluate submitted medical records and complex clinical cases.
• Synthesize clinical information to provide expert medical determinations on requested services.
• Perform utilization management activities.
• Support opportunities across care management, disease management, quality management, pharmacy management, post-service reviews, and clinical education.
• Ensure clinical decisions align with regulatory and compliance requirements.
• Apply national clinical guidelines, CMS policies and determinations, and trusted clinical reference sources.
• Collaborate with nursing teams through regular clinical discussions and provide medical expertise.
• Maintain responsibility for clinical accuracy, quality, and outcomes across a large clinical workforce.
• Serve as a clinical escalation resource in production environments.
• Progress into subject matter expert, trainer, and auditor responsibilities as experience develops.
• Support operational initiatives, clinical data analysis, and cross-functional projects focused on performance, efficiency, and patient outcomes.

Must-Have Qualifications

• Active Physician PRC license.
• Completed residency training in:
• Internal Medicine
• Family Medicine
• Medical Subspecialties
• Strong proficiency in Microsoft Office applications.
• Excellent communication, collaboration, problem-solving, and conflict-resolution skills.
• Strong ownership and results-driven mindset.
• Ability to work effectively across cross-functional teams.
• Ability to thrive in a fast-paced, dynamic, and team-oriented environment.

Good-to-Have

• Experience in utilization management or related clinical functions such as care management, disease management, quality management, pharmacy management, or post-service review.
• Experience serving as a clinical escalation resource.
• Experience as a clinical subject matter expert, trainer, or auditor.
• Experience with clinical data analysis or cross-functional clinical initiatives.