Quality Analyst (Clinical Claims)

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Skills you'll use

What you'll do

• Quality Monitoring & Evaluation
• 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.
• Reporting & Analysis
• 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.

Who can apply

• 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.

About Sutherland

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