Clinical Quality Management Analyst
Core
Develop and manage process improvement initiatives, conduct medical record reviews and audits, and ensure compliance with federal and state standards (CMS, NCQA) for quality medical care and service.
Role type
Clinical Quality Management Analyst
Builds
Quality improvement processes, compliance plans, and audit reports for member and provider satisfaction
Domain
Healthcare / Quality Management & Compliance
Required skills
Medical record review, ICD-10-CM coding, HEDIS/STARS metrics, HCC coding, regulatory compliance (CMS/NCQA), data analysis, process improvement, audit execution
Preferred skills
Project management, statistics, Total Quality Management (TQM) concepts
Technologies
Microsoft Office (Word, Excel, Access, PowerPoint), information systems
Responsibilities
Conduct retrospective, concurrent, and prospective audits; coordinate credentialing and re-credentialing; monitor regulatory changes and adjust compliance plans; educate providers on coding and quality standards; perform office site visits and medical record reviews
Seniority
Mid-level, hands-on IC