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.

🎯 Requirements

Active and unrestricted US Registered Nurse (USRN) license.
Minimum 2 years of recent clinical experience in hospital, utilization management, case management
At least 1 year of Quality Analyst experience in a BPO, healthcare, insurance, claims, or clinical
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.

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