About the company
Artificial Intelligence. Automation. Cloud engineering. Advanced analytics. For business leaders, these are key factors of success. For us, they’re our core expertise. We work with iconic brands worldwide. We bring them a unique value proposition through market-leading technology and business process excellence. We’ve created over 200 unique inventions under several patents across AI and other critical technologies.
Responsibilities
- Conduct regular audits of clinical claim reviews and related transactions.
- Evaluate adherence to client guidelines, operational procedures, and quality standards.
- Assess documentation accuracy, completeness, and compliance with established workflows.
- Ensure consistency in claim review decisions and quality outcomes.
- Maintain quality scorecards and audit documentation.
- Analyze quality trends, root causes, and performance gaps.
- Prepare and present quality reports to Operations leaders and stakeholders.
- Recommend corrective and preventive actions based on audit findings.
- Provide timely and constructive feedback to Clinical Claims Associates and Nurses.
- Partner with Team Managers in developing performance improvement plans.
- Support calibration sessions to ensure scoring consistency among quality evaluators.
- Identify learning opportunities and collaborate with Training teams.
- Ensure compliance with HIPAA, client policies, applicable healthcare regulations, and internal standards.
- Participate in process improvement initiatives to enhance quality, productivity, and customer experience.
- Support implementation of quality frameworks and continuous improvement programs.
- Escalate critical quality and compliance issues appropriately.
- Collaborate with Operations, Training, Workforce Management, and Client Services teams.
- Participate in client calibrations and quality discussions as needed.
- Contribute to business reviews and quality governance activities.
Requirements
- Active and unrestricted US Registered Nurse (USRN) license.
- Minimum 2 years of recent clinical experience in hospital, utilization management, case management, disability, health insurance, or related healthcare settings.
- At least 1 year of Quality Analyst experience in a BPO, healthcare, insurance, claims, or clinical operations environment.
- Strong understanding of healthcare documentation, claim review processes, and medical terminology.
- Knowledge of quality methodologies, auditing principles, and root cause analysis.
- Excellent analytical, coaching, and communication skills.
- Experience in performance monitoring.