The Role
Perform audits of clinical case reviews and calls to ensure accuracy, compliance, and adherence to regulations. Identify trends and quality improvement opportunities, provide constructive feedback and reports to clinical teams, collaborate with operations and training, maintain audit documentation, and support continuous improvement of QA frameworks and processes.
Summary Generated by Built In
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.
Skills Required
- Bachelor's degree in Nursing, Physical Therapy, Healthcare Administration, or related field
- Equivalent clinical certification
- Active and unrestricted Philippine nursing or clinical license
- Minimum of 2 years in clinical review or quality assurance within a healthcare or BPO setting
- Familiarity with HIPAA, URAC, and healthcare compliance standards
- Proficiency with healthcare management systems and electronic medical records (EMR)
- Proficiency with Microsoft Office applications
- Strong analytical abilities and attention to detail for identifying discrepancies and corrective actions
- Excellent verbal and written communication skills for delivering feedback and collaborating with teams
- Problem-solving skills to assess complex cases and propose process improvements
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The Company
What We Do
Founded in 1994 and headquartered in Conshohocken, Pennsylvania, MedRisk was established with a mission to revolutionize physical rehabilitation for workers' compensation patients. Over the last 30 years, the company has evolved into a leading managed care organization dedicated to physical rehabilitation and medical bill review for the casualty claims industry.
