QA Analyst Level III

MedRisk; United States; On-site; USD 85,000 - 120,000; Full time

Job summary

MedRisk is seeking a Quality Assurance Clinical Analyst Level III to ensure accuracy, compliance, and efficiency of clinical review processes within a healthcare setting. You will conduct audits, analyze trends, and drive quality improvement to enhance regulatory adherence and patient outcomes.

The role requires a Bachelor’s degree in Nursing or related field, US clinical license, 3+ years in clinical review or QA, and strong knowledge of HIPAA, NCQA, URAC, EMR systems, and MS Office.

Qualifications

• Bachelor's degree required; clinical certifications preferred.
• Active US nursing/clinical license preferred.
• At least 3 years in clinical review or QA in healthcare/BPO.
• Familiar with HIPAA, NCQA, URAC and compliance standards.
• Proficient in EMR and MS Office.
• Strong analytical, communication and problem-solving skills.
• Leadership experience to mentor junior staff.

Responsibilities

• Audit clinical reviews to ensure regulatory compliance and documentation accuracy.
• Identify quality improvements and drive efficiency in processes.
• Provide detailed feedback to clinical teams and training objectives.
• Collaborate with operations, training, and clinical reviewers.
• Contribute to QA framework development and best practices.
• Maintain audit findings and compliance reports for reviews.
• Stay updated on industry trends and regulations.
• Apply quality tools to improve audit accuracy.

Skills

Detail-oriented

Analytical

Communication

Problem-solving

Leadership

Mentoring

Education

Bachelor's degree in Nursing

Clinical licensure (US)

Equivalent certification

Tools

EMR systems

Microsoft Office

Healthcare IT

Job description

The Quality Assurance Clinical Analyst Level IIIis 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 processesare 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.