Clinical Quality Assurance Analyst

Integra Partners•Troy, MI

3d•Remote

About The Position

The Clinical Quality Analyst is responsible for monitoring, auditing, and documenting both clinical and non-clinical production quality in support of departmental goals and organizational standards. This role evaluates clinical documentation and decision-making across operational areas that require regulatory oversight, client-specific requirements, and compliance with medical policy, with an emphasis on accuracy, completeness, documentation quality, adherence to clinical and operational guidelines, and alignment with applicable regulatory and client standards. As needed, the role also performs non-clinical audits, including reviews of customer service interactions, system documentation, claims, administrative workflows, and other operational processes. The Clinical Quality Analyst participates in the development of quality monitoring formats and standards, ensuring fair and consistent evaluation practices across clinical and operational functions. This role provides clear, constructive feedback to team members and leadership, supports coaching efforts, and collaborates cross-functionally to identify trends, recommend solutions, and drive continuous improvement. The Clinical Quality Analyst documents audit results, prepares quality reports, and facilitates discussions with stakeholders to support service excellence and operational effectiveness across the organization

Requirements

Active, unrestricted LPN/LVN or RN license
Minimum 2 years of experience in Utilization Management or related clinical operations in a healthcare or managed care setting
Minimum of 1 year of experience performing Quality Assurance in a call center or other production-oriented service operations environment (or equivalent education and experience)
Strong knowledge of clinical review processes, regulatory requirements, and medical necessity criteria (e.g., InterQual, MCG)
Familiarity with UM software platforms and audit tools
Proficient understanding of QA methodologies and quality monitoring practices
Demonstrated ability to rapidly gain product, process, and tools knowledge and effectively communicate it to employees
Ability to analyze data to identify root causes of quality issues and propose actionable solutions
Excellent communication skills including listening, interpersonal, verbal, written, spelling, and grammar
Ability to coach/motivate employees with tact in order to facilitate optimal performance
Must exhibit leadership capabilities and interpersonal skills
Maintain confidential information and abide by necessary rules and regulations
Strong organizational, problem-solving, and analytical skills
Manage conflicting priorities while clearly communicating and managing expectations
Proficiency in Microsoft Office (Word, Excel, PowerPoint) for presentations and reports
Flexible and able to multitask and work with changing priorities with enthusiasm
Self-motivated, detail-oriented, and prepared to work independently or as an active team player
Ability to remain focused and motivated during the auditing process
Consistent track record of 95%+ in Quality and Production scores in current/previous roles
Experience conducting clinical or non-clinical audits or quality assurance reviews

Nice To Haves

Healthcare Quality Certification (e.g., CPHQ) or willingness to obtain within 12 months

Responsibilities

Audit clinical reviews and documentation, including medical necessity determinations, regulatory compliance, and adherence to medical policy
Ensure adherence to clinical guidelines, payer policies, and industry standards (NCQA, URAC, CMS, state and federal regulations.)
Complete and document audits using standardized quality monitoring tools
Collaborate with clinical and operational leadership, as well as training teams, to support targeted coaching, process improvement, and the development of content-based training that equips personnel with the skills needed for success
Maintain compliance with HIPAA and confidentiality requirements
Support special audits, regulatory readiness activities, and ad hoc analysis requests
Perform non-clinical audits as needed
Participate in and support the design of quality monitoring forms and quality standards
Record evaluations utilizing departmental quality monitoring forms
Collect, evaluate, report on, and track operational data against performance metrics
Prepare and analyze quality reports for management review
Prepare and facilitate quality calibration sessions with designated department leads
Facilitate meetings and prepare presentations related to insight analysis
Monitor trends and provide input or feedback on the information reported on
Identify, analyze, and share ways to optimize the quality monitoring process
Complete all evaluations, reports, and employee coaching sessions on a timely basis
Ability to learn new systems, tools, and methodologies as needed and continue progressing in a dynamic environment
Support ad hoc quality monitoring, reporting, and analysis activities based on operational needs
Work and communicate cross-departmentally