Job Description

Position Title:

Clinical Quality Evaluator- Core (PHL)

Shift:

Responsible for evaluating the quality of services and interactions provided by organizations within the enterprise. Primary duties may include, but are not limited to: Evaluates the quality and accuracy of transactions and/or communications with providers, groups, and/or policyholders. Identifies, documents, and reports any transaction errors or communications issues in a timely manner to ensure prompt resolution. Tracks and trends audit results, providing feedback to management. Conduct calibration sessions to evaluate and ensure that all teams are aligned with the set QA guidelines. Identifies and reports on systemic issues which create ongoing quality concerns. Conducts root cause analysis to determine the underlying causes of noted quality opportunities using the RCA tools. Recommend, implement, and monitor preventive and corrective actions to ensure that quality standards are achieved. Generates monthly reports of audit findings, supports clients with issues identified and develops reports to assist management with information requested. Produces other ad hoc reports as requested by internal and external clients. Associates at this level conduct routine to complex audits, generally related to one or more functions on one or more systems platform for one or more lines of business. Requires a BS Nursing degree. USRN license is required. At least 1 year bedside and/or utilizations management experience. At least 1 year QA experience. Working knowledge of healthcare industry and medical terminology, detailed knowledge of relevant systems and proven understanding of processing principles, techniques and guidelines; and ability to acquire and perform progressively more complex skills and tasks in a production environment required.