RN Quality Clinical Management Lead Analyst, Work from Home, Anywhere, USA

Major Duties and Responsibilities:


* Reviews and investigates potential quality of care (QOC) cases, which include, but are not limited to, adverse events, critical incidents and never events.



* Coordinates medical record requests, as appropriate, and reviews medical records to complete investigation.



* Works in collaboration with CMO, market medical directors and QOC Manager in the investigation of quality of care issues.



* Monitors quality of care issues and develops corrective action plans for areas of concern.



* Reviews and monitors high-risk, high-volume, and unusual events concurrently and retrospectively as they occur.



* Manages the occurrence reporting system ensuring timely and appropriate incident investigation, remediation and documentation.



* Prepares summary of findings, assigns severity levels to case, when appropriate, and prepares resolution letter to customer.



* Prepares and sends corrective action plans in collaboration with Medical Directors.



* Prepares case studies for presentation to Physician Advisory Committee (PAC).



* Assists with preparation of and may present quarterly reports to Corporate Quality Improvement Committee (CQIC) and PAC.



* Assists in the preparation, management and presentation of other Quality activities and reports including submission of all compliance related documentation.



* Maintains performance against established targets.



* Participates in inter-rater reliability testing to ensure consistency of reviews.



* Maintains knowledge of policies and procedures and assures team performs assigned duties in accordance with applicable regulatory requirements, State and accreditation standards.



* Performs other job-related duties as required;

Core Competencies and Skill Requirements:


* Strong knowledge of common patient disease processes and usual methods of treating them;



* Thorough knowledge of medical terminology and commonly used equipment;



* Ability to effectively evaluate medical records for appropriateness of care;



* Ability to assess and judge the clinical performance of physicians and other health professionals;



* Strong analytical, assessment and problem-solving skills;



* Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards;



* Intermediate skills in Word, PowerPoint, Excel, and Outlook with basic ability to enter data into and navigate through a database;



* Maintains confidentiality of all sensitive documents, records, discussions and other information generated in connection with quality of care activities;



* Self-directed and able to work independently.

Uses appropriate judgment to seek assistance and ask questions ;



* Keeps QOC Manager updated on overall activities, issues identified, and actions to address issues;



* Strong attention to detail and w...