Clinical Quality Analyst Resume Samples
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Clinical Quality Analyst Resume Samples
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CF
C Fritsch
Cornelius
Fritsch
74619 Fisher Causeway
Los Angeles
CA
+1 (555) 946 3852
74619 Fisher Causeway
Los Angeles
CA
Phone
p
+1 (555) 946 3852
Experience
Experience
New York, NY
Clinical Quality Analyst
New York, NY
Stark Inc
New York, NY
Clinical Quality Analyst
- Reviewing provider policies, procedures and documentation standards and identify areas of improvement, during initial and re-credentialing audits
- Meet and work collaboratively with other Clinical Quality Analysts on the Provider Performance team on a regular basis
- Performing product testing, validation and packaging activities
- Interpreting the information gathered during a QOC audit to develop reports to requesting committees, with recommendations of corrective action
- Supporting medical directors, product management, sales, marketing, training, implementation, account management and customer support staff
- Reviewing provider policies, procedures and documentation standards and identify areas of improvement, during initial and re - credentialing audits
- Responsible for health promotion activity plan, development and implementation
Boston, MA
Senior Clinical Quality Analyst
Boston, MA
Wolff, Gleichner and Harber
Boston, MA
Senior Clinical Quality Analyst
- Develop and implement improvement projects and using data to develop intervention strategies to improve outcomes
- Establish and maintain strong business relationships with providers and internal business partners
- Ensure all implementations are executed on time, on budget, and with quality
- Develop, analyze and monitor new, routine and ad hoc reports using multiple data sources and systems
- Identifies issues and trends in coding and documentation that affect provider risk adjustment factor scores
- Participate in designing, creating and implementing quality improvement projects and initiatives
- Educate practitioners / clinical staff and provide ongoing clinical guidance related to the Risk Adjustment process
present
Los Angeles, CA
Hedis Clinical Quality Analyst, Senior
Los Angeles, CA
Paucek-Brown
present
Los Angeles, CA
Hedis Clinical Quality Analyst, Senior
present
- Design, create and implement Quality Improvement projects and initiatives
- Provide analytical support and expertise when compiling and reporting information
- Develop and present recommendations and alternatives for management and executive review
- Assume responsibility for data integrity among various internal groups and/or between internal and external sources
- Lead and/or mentor associates
- Assist in developing department strategic action plans including identification of objectives, goals and strategies
- Develop and implement effective analysis, research and evaluation of quality management metrics
Education
Education
Bachelor’s Degree in Business
Bachelor’s Degree in Business
Loyola University Chicago
Bachelor’s Degree in Business
Skills
Skills
- Excellent interpersonal, organization, problem solving, analytic and communications skills. Ability to influence/negotiate
- Ability to work independently and handle multiple projects simultaneously
- Strong analysis/problem solving
- Self-Starter/ Motivated
- Demonstrated proficiency MS office, Intranet/Internet governmental applications
- Knowledge; procedural/technical writing; evaluation methodologies
- Excellent verbal and written communications
- Knowledge of URAC standards (CORE/UM/CM/HIPPA/Health Network) desirable
- Operates personal computers, printers, facsimile, telephones, copy machines and other commonly used office accessories/equipment
- Physical activity may include: twisting, reaching, kneeling, bending, stooping, squatting, crawling, grasping, grabbing, pushing, pulling, repetitive motion, climbing, etc
15 Clinical Quality Analyst resume templates
Read our complete resume writing guides
1
Clinical Quality Analyst, Harborview Resume Examples & Samples
- Using findings from data analysis, work collaboratively with CMMI Grant-CPI Teams and operational staff to develop systems to improve clinical practice, and monitor system change
- Independently organize and present clinical practice data and analysis for the CMMI-CPI team review
- Independently develop and implement systems to validate data integrity
- Possible data Abstraction from multiple medical records to support the CMMI Grant-CPI Teams
- Ensure timely data submission for team work
- Works with Performance Measurement and quality data experts to provide reports and data sets
- Working with UW Medicine Clinical experts, assists in the analysis of current and proposed CMMI Grant-CPI quality initiatives and programs in the area of quality indicator definitions, clinical risk adjustments, qualifying clinical procedures or practices, and qualifying patient volumes
2
Clinical Quality Analyst Resume Examples & Samples
- Reviewing provider policies, procedures and documentation standards and identify areas of improvement, during initial and re-credentialing audits
- Traveling to conduct on-site provider audits throughout Western New York
- Responsible for providing feedback and recommendations on how to improve areas of deficiency related to provider deficiencies of policies, procedures, and documentation standards during initial and re-credentialing audits
- Interviewing and investigating quality of care (QOC) concerns, and gaining an understanding of the underlying issues which may have caused the concern
- Interpreting the information gathered during a QOC audit to develop reports to requesting committees, with recommendations of corrective action
- Conduct ongoing audits to fulfill contractual requirements
- Responsible for developing the interviewing strategy prior to completion of the audit in order to answer the concerns related to the initial complaint
- Scoring audits and writing audit reports
- Working to ensure our members receive the best possible treatment from a network of high-quality providers
- Master’s degree with independent licensure in the Mental Health field such as: LCSW, LMFT / MFT, LMHC, LP, or licensed PhD; OR RN license with experience in mental health
- A minimum of 2 years of experience in behavioral health
- A Master's degree or RN with experience in mental health
- A minimum of 6 months of experience with managed care
- Familiarity with standards for NCQA and The Joint Commission
3
Clinical Quality Analyst Resume Examples & Samples
- Meet and work collaboratively with other Clinical Quality Analysts on the Provider Performance team on a regular basis
- Traveling to conduct on-site provider audits throughout Nebraska
- Master’s degree with independent licensure in the Mental Health field such as: LIMHP, LP, or licensed PhD; OR RN license with experience in mental health
4
Clinical Quality Analyst Resume Examples & Samples
- Excellent interpersonal, organization, problem solving, analytic and communications skills. Ability to influence/negotiate
- Ability to work independently and handle multiple projects simultaneously
- Strong analysis/problem solving
- Self-Starter/ Motivated
- Demonstrated proficiency MS office, Intranet/Internet governmental applications
- Knowledge; procedural/technical writing; evaluation methodologies
- Excellent verbal and written communications
- Knowledge of URAC standards (CORE/UM/CM/HIPPA/Health Network) desirable
5
Senior Clinical Quality Analyst Resume Examples & Samples
- Supports Quality Improvement Projects (QIP) by identifying and collecting relevant data, monitors progress and analyzes outcomes. Updates QIP documentation regularly
- Develop and implement improvement projects and using data to develop intervention strategies to improve outcomes
- Bachelor's degree or higher in a healthcare related field
- 3+ years clinical experience-hospital, community, or managed care
- 2+ years of experience in quality improvement, this includes developing and implementing performance improvement projects
- 2+years demonstrated analytical experience preferred using quality data i.e. develop intervention strategies to improve outcomes
- Demonstrated ability of writing skills, i.e. Project Report Documents
- 2+years of Project Management experience
- Critical and analytical thinking required
- Role requires travel to physician offices locally up to 20% of their time
- Knowledge of Managed Long Term Services and Support (MLTSS) or Medicare experience
- RN Licensure
6
Lead Clinical Quality Analyst Resume Examples & Samples
- This position will require knowledge of existing clinical quality measures, and understanding of how measures are developed, and familiarity with clinical quality measure specifications. Additionally a knowledge of electronic health records and standards for electronic information exchange such as HL7 is required. Position requires ability to interpret quality data for evaluation of programmatic results, and to write descriptions of measures and their uses, suitable for a non-technical audience
- Candidates should be able to interface with high-ranking members of federal healthcare agencies, think creatively and be prepared to contribute to innovative CQM programs and guide approaches to solutions based on a clinical understanding of the issues
- Master’s degree in Informatics,, Public Health, Nursing, or related field. Healthcare quality measure credentials strongly preferred 7 years related experience with healthcare quality measures including eCQMs and EHR data standards experience
7
Senior Clinical Quality Analyst Resume Examples & Samples
- Analyzes progress notes and documentation sent by providers for validation following CMS guidelines and ICD-9 / ICD-10 Coding Manual guidelines and enters final results into appropriate database
- Ensure documentation is being accurately coded and all diagnosis codes are captured
- Identify potential suspects through clinical documentation and reporting
- Must have a strong understanding of medical terminology, disease process and anatomy and physiology
- Recommend processes to ensure accurate and efficient coding practices based on Medicare Advantage coding guideline
- Performs the minimum number of reviews consistent with established departmental goals
- Identifies issues and trends in coding and documentation that affect provider risk adjustment factor scores
- Develops relationships with clinic providers and communicate coding and documentation guidelines through coding education sessions with providers throughout the year
- Educate practitioners / clinical staff and provide ongoing clinical guidance related to the Risk Adjustment process
- Supports best practice for provider engagement
- Successful completion of a coding certificate program RHIA, RHIT, CCS, CCS-P, or CPC-H status
- Skilled in MS Word
- Minimum productivity of 8 encounters per hour with minimum 95% accuracy rate
- Advanced knowledge of medical coding and billing systems and regulatory requirements
- Advanced knowledge of auditing concepts and principles
- Associate's degree in related field and/or equivalent and relevant work experience
- 3+ years experience in ICD-10 coding, reimbursement, clinical documentation improvement and health information technology
- Hospital and HCC coding experience
8
Clinical Quality Analyst Resume Examples & Samples
- Perform clinical quality assurance testing of Advanced Clinical Decision Support (ACDS) products
- Create fictional test patient records with various characteristics to make sure that the ACDS products behave correctly and provide the right advice
- Create test plans to make sure that sufficient test cases are considered
- Execute the test plans
- Work closely with the Engineering QA team to develop testing automation tools
- Participate in multi-disciplinary team meetings
- Work closely with the Clinical and Informatics teams to address any issues uncovered through the testing
- Work closely with the Clinical, Informatics, and Engineering teams throughout the product development lifecycle to ensure that project plans incorporate sufficient clinical quality assurance testing
- At least two years’ experience with Health IT software (required)
- Demonstrated ability to work with cross-functional teams (required)
- Experience working with biomedical vocabularies such as ICD-10-CM, RxNorm, LOINC and SNOMED (preferred)
- Knowledge of Health IT standards, such as FHIR® and C-CDA (preferred)
9
Clinical Quality Analyst Resume Examples & Samples
- Implementing the development and maintenance of quality measures
- Working project teams that use the Symmetry Suite of products
- Identifying enhancement opportunities and proposing solutions
- Supporting medical directors, product management, sales, marketing, training, implementation, account management and customer support staff
- Creating and maintaining supplemental product documentation
- Performing product testing, validation and packaging activities
- Minimum of 3 years of healthcare work experience with exposure to quality measurement
- Solid PC computer skills with proficiency in MS Office applications, especially Excel and Access
- Strong knowledge of administrative claims data
- Knowledge of medical coding systems (i.e. CPT, HCPCS, ICD-9, NDC)
- Ability to think both strategically and tactically
- Ability to understand complex applications and derive solutions
- Excellent written/oral communication and listening skills
- Healthcare-related degree
- Informatics experience
- Data Analyst experience
- Implementing quality measurement experience with programs such as HEDIS, Medicare Stars, CMS PQRS
- Experience building logic for quality measures
- Knowledge of Symmetry products is desired, preferably EBM Connect
- SQL Experience
10
Hedis Clinical Quality Analyst, Senior Resume Examples & Samples
- *This position can be located at any UnitedHealth Group location in the U.S.***
- Assist with the implementation of the National HEDIS improvement plan, including the HEDIS data collection and clinical improvement projects
- Participate in determination of annual HEDIS strategy as well as other clinical improvements
- Collaborate with the HEDIS Project Managers in the collection of RFI, ROADMAP and HOQ information for HEDIS
- Participate with Regional Quality Team to identify and implement region and or state-specific projects to improve HEDIS scores, CMS Star Ratings and other metrics
- Participate in regional quality programs and committees as needed
- Identify opportunities and actively participate in process improvements related to enhancing health plan quality
- Assist in developing targeted educational reminders for clinical/preventive initiatives
- Minimum of Bachelor's Degree
- 3+ years of experience extracting data in SQL/Oracle environment
- 2+ years of exerience developing and implementing performance improvement projects, or using data to develop intervention strategies to improve outcomes
- Ability to collect, analyze, and present data
- Prior experience creating reports related to quality improvement/performance outcomes
11
Hedis Clinical Quality Analyst, Senior Resume Examples & Samples
- Join the United Clinical Services Team and live Our United Culture everyday! Integrity, Compassion, Relationships, Innovation and Performance
- Healthcare/Health Plan experience
- HEDIS experience and/or knowledge
- Strong data management and/or project management skills
- Minimum of 2 years Healthcare/Health Plan experience
- Experience working with HEDIS software vendors (management, building relationships, issue resolution etc.)
- Experienced in medical record review
- Proficiency with Microsoft Access
- SAS and/or SQL experience
- Basic statistical knowledge and application of continuous quality improvement concepts, such as Six Sigma or PDSA
12
Clinical Quality Analyst Resume Examples & Samples
- Extract appropriate metrics from SQL or Oracle environments
- Develop and present recommendations and alternatives for management and executive review
- Develop and implement effective analysis, research and evaluation of quality management metrics
- Develop, analyze and monitor new, routine and ad hoc reports using multiple data sources and systems
- 1+ year managed care experience
- 2+ years of behavioral healthcare experience
13
Clinical Quality Analyst, Senior Resume Examples & Samples
- Design, create and implement quality improvement projects and initiatives
- General understanding of HEDIS measures
- Conduct research, complete data mining, and other necessary tasks to identify and validate business and HEDIS reporting requirements
- Work on ad hoc projects as assigned
- 3+ years health plan experience in claims, coding, contracting, or reimbursement
- 2+ years of experience with coding and reimbursement methodologies & policies (e.g. CPT, HCPCS, ICD-9, ICD-10, CMS, etc.)
- Experience with one or more of the following platforms/applications- UNET/TOPS, FACETS, COSMOS, Pulse and/or NICE, ppoONE, internal claims processing platforms
- Intermediate knowledge of CMS 1500 and UB04 data elements
- Intermediate level of proficiency in MS Excel, Access, PowerPoint and Word
- Ability to analyze and translate data to determine impact and develop recommendations for action plans
- Collaborative team player
- Ability to work independently in a virtual team environment and escalate issues to program leadership as appropriate
- Knowledge of Medicare and Medicaid guidelines
- Strong organizational/time management skills and be able to work independently, exercising judgment and utilizing claims and coding expertise
- Ability to work in cross-functional team
- 2+ years HEDIS and/or Medicare Risk Adjustment (HCC) analysis experience
14
Clinical Quality Analyst Resume Examples & Samples
- Collect Quality data and/or information based on applicable standards, state/federal or other regulations, customer or consumer requests, internal requests, or project assignments
- Identify appropriate sources for data or information either internally or externally and collect data/information
- Develop effective methods for data/information collection
- Identify appropriate data platform or application (e.g., data bases, Intranet source, Internet source) and utilize to collect data or information
- Investigate Quality problems identified and collect additional information to close gaps
- Work cross functionally and coordinate with others internally or externally to gather information; overcome challenges to obtaining
- Needed information
- Mine data and/or information to identify inconsistencies, trends, other information needed, etc. (e.g., develop and/or run data queries)
- Analyze and interpret data or information (e.g., clinical, administrative, Quality) to ensure they meet standards, are compliant and/or are accurate and complete
- Provide explanations or updates when data/information (e.g., clinical, administrative) are not accurate or unclear
- Explain the characteristics of the data/information (e.g., clinical, administrative) including any unique attributes
- Identify Quality improvement or intervention opportunities and work cross-functionally to develop interventions or recommendations
- Manage key relationships (e.g., vendors, stakeholders, regulatory bodies) to ensure milestones are achieved and performance objectives are met
- Bachelor’s degree or equivalent related experience
- 3 years’ experience in healthcare industry
- Advanced Excel skills
15
Clinical Quality Analyst Resume Examples & Samples
- Support the coordination of care efforts for EPSDT aged members, by tracking annual well visits, immunizations and follow up on the referrals for specialized services
- Support health plan coordination actions associated with Arizona Early Intervention Program (AzEIP) efforts to offer support and services for children with developmental delays or disabilities
- Manage projects designed to improve member utilization of preventative health services
- Create reports and presentation materials using Microsoft Excel, MS Access, or other data manipulation software
- Assists health plan to maintain State contracted QI standards
- Assists in implementing QI activities for the health plan
- Assists Quality Manager/ QM Director in meeting all regulatory quality requirements
- Assists with the maintenance of Quality policies & procedures; makes recommendations to other departments for the development of policies and procedures to meet the quality goals of the plan
- Responsible for ensuring timely submission of and meeting all state QI reporting requirements
- Bachelors of Science degree
- 2+ years of project management experience, or 2+ years of quality improvement experience
- Ability to use databases and prepare reports as needed using various data manipulation and presentation software such as Microsoft Access, Microsoft Word, Microsoft Excel, and Microsoft PowerPoint
- Ability to professionally interact with medical staff, peers, and internal company staff at all levels
- Ability to visit physician offices to present information
- Must have valid state-specific driver's license and reliable vehicle
- Strong communication skills with both internal and external clients
- Experience working with quality improvement activities
- Experience working for a Medicaid and/or Medicare health care regulator or insurance organization
16
Senior Clinical Quality Analyst Resume Examples & Samples
- In Office Position*
- Design, create and implement Quality Improvement projects and initiatives
- Conduct and manage outcomes of various studies that may include analyzing, reviewing, forecasting, trending and presenting information for quality management planning and management needs
- Provide analytical support and expertise when compiling and reporting information
- Assume responsibility for data integrity among various internal groups and / or between internal and external sources
- Lead and / or mentor associates
- Extract monthly MedMeasures summary reports and identify gaps
- 3+ years of Healthcare Experience
- Ability to navigate Microsoft Access Databases
- Create, edit, save and send documents utilizing Microsoft Word and Excel
- Ability to collect, analyze and present data
- 3+ years' experience extracting data from multiple sources
- Medicaid managed care compliance background
17
Clinical Quality Analyst Resume Examples & Samples
- Uses pertinent data and facts to identify and solve a range of problems within area of focus or expertise
- Mine claims and case management software for data to assist in the development of preventive care programming as well as determine outcomes of implemented programs
- Provides explanations and information to others on topics within area of expertise
- Solves moderately complex problems and / or conducts moderately complex analyses
- Works with some guidance; seeks guidance on only the most complex tasks
- Translates concepts into practice
- Acts as a resource for other STARS Quality Analysts with less experience
- Some proficiency in understanding of basic process management and total quality management principles and methodologies (e.g., Six Sigma; Lean)
- Demonstrate understanding of relevant organizations' operations, products and applications, strategies, processes, and / or business priorities in order to build effective solutions
- Some proficiency in understanding of upstream and downstream impacts to partners of business process operations and solutions
- Engage and often directly support Quality auditing activities to validate process performance
- Support the analysis of quality auditing findings as it relates to business process information (e.g., metrics; analytics) to identify key issues, trends, and potential root causes (e.g., training issues; lack of understanding by user community) that point to improvement opportunities
- Support engagement with relevant stakeholders (e.g., end users; SMEs; sponsors) to establish appropriate criteria and goals (e.g., efficiency; effectiveness) in order to direct investigation into problems and potential solutions
- Support the estimation and / or quantify potential benefits, costs, and resource requirements associated with recommended business process solutions
- Support the summarization and communication of proposed solutions with the appropriate audiences in a manner tailored to their understanding, level, or experience
- Support the communication of potential impacts and risks associated with implementing proposed solutions, progress of actions taken to resolve risks and gaps identified
- Intermediate to expert with MS Office including Word, Excel and PowerPoint and Access
- Intermediate to expert SharePoint experience including utilization and site maintenance
- Intermediate or Expert Visio experience (or like software)
- Dynamic verbal and non-verbal communicator who can create and maintain a collaborative work environment with critical business partners including executive leadership
- Proven record of positive, effective coaching and development ability as well as supporting effective team interactions
- Prior experience with HEDIS preferred
- Prior experience with Health Insurance industry
- 2+ years in a role supporting a quality function or related operational function preferred
- 1+ years of project management experience
18
Clinical Quality Analyst Resume Examples & Samples
- Independently use discretion and judgment to evaluate subjective clinical documentation of member records and engagements to assess performance of nursing skill
- Applies advanced knowledge to conduct multispecialty subjective assessments to evaluate the skills of nurses. Multispecialty programs include Maternity, Oncology, Treatment Decision Support, Case Management, Disease Management, RN Advocacy and Complex Medical Conditions across all lines of business; Medicaid, Medicare, Duals, and Commercial
- Consults with Medical Directors to calibrate on subjective assessments to ensure consistency of feedback related to complex, high risk cases
- Responsible to ensure evaluation tool components for subjective skill assessments comply with quality standards and follow Optum's policies, State regulations and Accreditation standards
- Assist the Clinical Management team, as needed, to determine areas that require immediate remediation and assist Optum’s employees to stay ahead of changing information while improving the quality and effectiveness of nurse and consumer engagement
- Participate in training and performance improvement related projects to support staff development as well as assist with the training of new employees
- The Clinical Quality Analyst will highlight key findings for implementation of performance improvement plans when necessary
- Work with colleagues across business units to ensure that process and procedural changes are reflected in staff member’s documentation such as job aids and policies
- Assist with gathering data for routine reporting with other team members to be used for day-to-day purposes and at meetings
- Maintain a tracking tool that will log unacceptable areas in the workflow and staff documentation performance indicating improvement is needed for discussion with management and/or at departmental team meetings
- Must stay abreast of all customer specific details, to ensure high quality customer service
- CCM certification
- Medicaid Experience
- 3+ years clinical experience in a hospital, acute care, home health / hospice, direct care or case management
- 1+ year in a Clinical Contact Center environment required. Proven customer service skills and experience
- 2+ years of clinical audit experience preferred (preferably sales and customer service)
- Bi-lingual Candidates Desired (English/Spanish)
19
Clinical Quality Analyst Resume Examples & Samples
- Direction and guidance on quality improvement and management programs including accreditation
- Conducts and supports accreditations and certification audits for URAC, ACHC & NCQA requirements
- Reports and analyzes quality of care from a member perspective and develops plans and programs to support continuous quality improvement using appropriate tools to meet accreditation and certification requirements
- Ability to assess and / or document business processes
- Collaborate with project team members to create detailed documentation
- Systematic and qualitative problem solving
- Collect Quality data and / or information based on applicable standards, state / federal or other regulations, customer or consumer requests, internal requests, or project assignments
- Develop or update work plans (e.g., annual work plan)
- Develop or update program descriptions (e.g., annual program descriptions)
- Develop program evaluations (e.g., annual program evaluation)
- Review results, conduct analyses (e.g., evaluate against goals / effectiveness of interventions over time), and prepare reports on findings
- Experience in leading and performing audits and qualify to take certified auditor exam
- Professional presentation
- Knowledge of Managed Care, Health Systems, PBMs, pharmacies, etc
- Ability to read and interpret regulations and standards and create cross - reference matrix of deliverables
- Ensure project requirements meet all applicable standards
- Proficient in MS Office (Word, Excel, PowerPoint and Outlook)
- Ability to manage multiple projects and tasks
- Ability to work with a variety of staff and disciplines at all levels throughout the organization
- Develop audit or review processes (e.g., automated / technically driven)
- Experience leading and performing audits
- Proficient utilizing MS Office (Word, Excel, PowerPoint and Outlook)
- Accreditation, Compliance or Quality Improvement experience
- Experience working as a Pharmacy Technician in a Mail Service Pharmacy, Specialty Pharmacy or PBM
- Proficient with Visio and SharePoint
- Experience in retail, mail order and / or specialty pharmacy
- Experience working in a (PBM) pharmacy benefit management functional area
- Serve as a resource providing explanations and expertise (e.g., accreditation, providing information to others, satisfaction survey, interventions)
20
Clinical Quality Analyst Resume Examples & Samples
- Providing business analysis and interpretation of quality measure specifications to technical teams in the deployment of quality measures
- Working within a team of other quality business analysts, technical engineers, and quality control analysts to ensure end-to-end production of accurate rules engine logic
- Participating in product testing, validation and documentation activities
- Minimum of 3 years of data analysis experience
- Exposure to the interpretation of national quality measurement specifications
- Experience with project and/or product management and lifecycles
- Excellent evaluative, analytical and problem-solving skills
- Ability to understand complex requirements and derive solutions
- Solid PC computer skills with proficiency in MS Office applications (Word, Excel)
- Working knowledge of administrative claims data and medical coding systems (i.e. CPT, HCPCS, ICD-10, NDC)
- Understanding of clinical taxonomies (SNOMED, LOINC, RxNORM, etc)
- Experience implementing aspects of national quality measures (through provider groups, payers, state/federal institutions), such as HEDIS, Medicare Stars, PQRS, Meaningful Use, State Medicaid programs. This experience could include quality improvement initiatives, reporting, EHR/Practice Management data analysis, etc
- Understanding of data inputs, outputs, relational database concepts
- Experience with SQL or Microsoft Access
21
Clinical Quality Analyst Resume Examples & Samples
- Creation and implementation of a coding accuracy and improvement program for the Utah market
- Create and execute the plan for improvement across the UT market
- Work with network managers, medical director, market leader, stakeholders and other employees to ensure improvement in coding accuracy
- Focus on improvement via internal and external education, innovative programs and provider engagement
- Work closely with local teams as well as corporate teams
- Coding review and education with providers and team
- Clinical Quality Documentation assessment
- Work Plans for CDQI
- Cross-functional collaboration with multiple teams and functions
- High School Diploma/GED or higher education
- 2+ years of experience in a coding or billing role
- Certification in Coding (AHIMA or CPC)
- Experience educating others to improve results in clinical coding
22
Senior Clinical Quality Analyst Resume Examples & Samples
- Enable providers to submit necessary clinical data through one of multiple methods within the enterprise and external vendors
- Ensure all implementations are executed on time, on budget, and with quality
- Immediately recognize and communicate barriers to goals and lead solutions and escalations to remediate these barriers in a timely manner
- Establish and maintain strong business relationships with providers and internal business partners
- Enable successful remediation of identified quality issues which reside with external business partners for remediation
- Serve as a resource to other team members; share best practices and increase team effectiveness
- Track and report all provider engagement statuses in a timely and high quality manner in salesforce.com
- Relevant Bachelor’s degree, certifications, and/or work experience equivalent
- 3+ years of experience working with clinical data and clinical data exchange solutions including HL7 and related interoperability standards such as v2.x messages/message files, CCD, HITSPC32/CCD, C-CDA,CDA unstructured documents, CALINX, IHE profiles, etc
- Self-managing and self-directing
- Ability to formulate and execute solutions to problems with minimal guidance
- Experience using salesforce.com or similar CRM applications
- Excellent communication skills with team members and business partners
- Highly proficient utilizing Microsoft Office applications
- Ability to grasp new technical concepts with limited knowledge
23
Senior Clinical Quality Analyst Resume Examples & Samples
- Participate in designing, creating and implementing quality improvement projects and initiatives
- Participate in data collection, organization and analysis related to quality monitors and activities in compliance with relevant state / government requirements
- Participate as necessary in preparation of QM reports; provide analytical support and expertise when compiling and reporting information
- Manage quality of care complaints
- Support ongoing monitoring and compliance with QM Policies and Procedures
- Participate in preparation of materials and evidence necessary for audits related to QM
- Interface with key departments, as necessary in order to implement QM Program
- Assist with preparation and facilitation of QM Committees
- Participate in relevant department and essential QM Committee meetings and workgroups in order to implement QM Program
- Participate, as relevant, in Peer Review activities
- 3+ years of healthcare experience
- Intermediate computer skills (Microsoft Word, Excel and Outlook ) with the ability to navigate a Windows environment. Create, edit, save and send documents utilizing Microsoft Word
- 1+ years’ experience collecting, analyzing and presenting data
- Bachelor's Degree in behavioral health or related field
- LPC, MSW, LCSW, LCPC
- CPHQ a plus
- Knowledge and previous experience with national QI standards (NCQA, URAC HEDIS) helpful and desirable
- Prior experience creating reports related to quality improvement/performance outcome
24
Clinical Quality Analyst Resume Examples & Samples
- Experience in medical record review
- Experience with data or project management
- Excellent time management and prioritization skills
- Experienced in HEDIS Operations
- Minimum of 2 years HEDIS experience and/or knowledge
- Experience working with Providers/Provider Groups
- Experience working with HEDIS medical record vendors (management, building relationships, issue resolution etc.)
25
Hedis Clinical Quality Analyst Resume Examples & Samples
- Undergraduate degree or demonstrated equivalent experience
- Experience working with Providers or Vendors; demonstrated ability specific to building relationships and issue resolution
- Excellent team development skills
- Strong proficiency with Microsoft Office applications, including: Word, Excel and PowerPoint
- Solid knowledge of managed care requirements related to clinical quality
- Knowledge of CMS STARs
- Experience coordinating work streams across multiple business partners, emphasis on collaboration and issue resolution
- Clinical and/or Health Education experience (RN or LPN desired)
- Application of continuous quality improvement concepts, such as Six Sigma or PDSA
26
Clinical Quality Analyst Senior Resume Examples & Samples
- Identifies solutions to non-standard requests and problems
- Provides explanations and information to others on difficult issues
- Coaches, provides feedback and guides others
- Collect Quality data and / or information based on applicable standards, state / federal or other regulations, customer or consumer requests, internal requests or project assignments
- Identify appropriate sources for data or information either internally or externally and collect data / information
- Develop effective methods for data / information collection
- Work cross functionally and coordinate with others internally or externally to gather information; overcome challenges to obtaining needed information
- Mine data and / or information to identify inconsistencies, trends, other information needed, etc. (e.g., develop and / or run data queries)
- Analyze and interpret data or information (e.g., clinical, administrative, Quality) to ensure they meet standards, are compliant and / or are accurate and complete
- 3+ years' experience extracting data in SQL / Oracle environment
- Intermediate computer skills (Microsoft Word, Outlook and Internet) with the ability to navigate a Windows environment
- 2+ years' experience developing and implementing performance improvement projects or using data to develop intervention strategies to improve outcomes
- Demonstrated ability to manage multiple projects simultaneously
27
Clinical Quality Analyst Resume Examples & Samples
- Accurately identifies real/potential performance problems affecting the organization and recommend solutions with follow-through and communication
- Analyzes sequences and prioritizes assignment of deficient records; forwards to designated staff for completion
- Develops and generates reports to identify population for quality measures
- Promotes effective working relations and works effectively as part of a department/unit team inter- and intradepartmental to facilitate the department’s/unit’s ability to meet its goals and objectives
- Perform other duties assigned
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Clinical Quality Analyst Resume Examples & Samples
- Traveling up to 75% of the time to conduct on - site facility, agency, and clinician audits throughout a given region
- Working to ensure our members receive the best possible treatment from a network of high - quality clinicians and facilities
- Attending team meetings by phone to stay up - to - date on issues and discuss inter - rater reliability
- Developing your own travel schedule
- Sending letters and samples of audits to providers
- Tracking and documenting all activities
- Licensure in the Mental Health field such as: LICSW, LMFT, LP, LPC, LPCC, PhD or an RN license
- License must be independent, active and unrestricted
- 6+ months of experience with managed care
- 2+ years of experience in behavioral health
- Quality improvement knowledge NCQA
- JCAHO familiarity
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Clinical Quality Analyst Resume Examples & Samples
- Independently use discretion and judgment to evaluate subjective clinical documentation of member records and engagements to assess performance of nursing skills
- Applies advanced knowledge to conduct multispecialty subjective assessments to evaluate the skills of nurses
- Multispecialty programs include Maternity, Oncology, Treatment Decision Support, Case Management, Disease Management, RN Advocacy and Complex Medical Conditions across all lines of business; Medicaid, Medicare, Duals, and Commercial
- 1+ year in a Clinical Contact Center environment
- Proven customer service skills and experience
- Bi-lingual Candidates (English/Spanish)
- Medicare Experience
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Clinical Quality Analyst Resume Examples & Samples
- Independently use discretion and judgment to evaluate subjective clinical documentation of member records and call engagements to assess performance of nursing skills
- Assist’s Optum employees to stay ahead of changing information while improving the quality and effectiveness of nurse and consumer engagement
- The Clinical Quality Analyst will highlight key findings to share with site managers for coaching purposes
- Ensure that process and procedural changes are reflected in staff member’s documentation such as job aids and policies
- 2+ years of clinical audit experience
- HCDS Experience
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Clinical Quality Analyst Resume Examples & Samples
- Reviewing provider policies, procedures and documentation standards and identify areas of improvement, during initial and re - credentialing audits
- Traveling to conduct on-site provider audits throughout Missouri
- Responsible for providing feedback and recommendations on how to improve areas of deficiency related to provider deficiencies of policies, procedures, and documentation standards during initial and re - credentialing audits
- Working to ensure our members receive the best possible treatment from a network of high - quality providers
- Master’s degree with independent licensure in the Mental Health field such as: LCSW, LMFT, LP, LPC, or licensed PhD; OR RN license with experience in mental health
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Tricare Clinical Quality Analyst Senior Resume Examples & Samples
- Assume responsibility for data integrity among various internal groups and/or between internal and external sources
- Lead and/or mentor associates
- Assist in developing department strategic action plans including identification of objectives, goals and strategies
- Collaborates with the Business Analyst for all required reporting
- Ability to navigate Microsoft Access Databases and VBA
- Military experience/exposure
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Clinical Quality Analyst Resume Examples & Samples
- Positions in this function are responsible for assisting on clinical Training quality improvement and management programs
- Assists with and may conduct clinical Training quality audits of materials; monitor accuracy of material publishing including: material updates, catalog, lists/libraries, archiving, index updates; work with support staff toward solutions when there are inaccuracies
- Training Material Gatekeeper
- Responsible for the data collection of Training quality and for assisting with the development of plans and programs to support continuous quality improvement
- Collecting and requesting data to support training department
- Assist with analyzing data and identify risks
- Meeting with stakeholders, as appropriate
- Presenting findings to manager or support staff
- Maintaining training team SharePoint (SP) sites in order to develop solutions for manual processes, drive efficiencies, and improve/maintain user functionality
- Excel skills (Pivot Tables, Macro’s); Ability to utilize MS Excel to collect data
- 2+ years previous data collection experience
- Effectively function and consistently produce high quality error free work product in a dynamic / fluid environment
- Experience in LearnSource
- Experience in Metrics That Matters (MTM)
- Experience using WebEx
- Knowledge in e-learning/computer based development, i.e. Articulate Storyline
- Previous experience with PowerPoint to develop presentations or update existing presentations
- Experience with quality and performance improvement
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Clinical Quality Analyst Resume Examples & Samples
- Working with the Director / Manager of Clinical Quality to create and implement multiple strategies, work plans, policies and procedures and documents to maintain compliance with state and federal regulatory requirements including the Centers for Medicare & Medicaid Services, state Medicaid and NCQA accreditation standards
- This person will be the lead to ensure the work plan is in place to meet the requirements on a timely basis and the documentation is ready for the next NCQA survey and other regulatory requests
- 1+ years of experience in a project driven environment
- Bachelor's degree in Healthcare Administration, Social Sciences, Business or Analytical field
- Strong writing and analysis skills
- Excellent communication, writing, organization, analytical, project management, and critical thinking skills
- Ability to research various venues to obtain pertinent data; design and present project findings; and prioritize and meet deadlines (must be able to balance multiple tasks / projects)
- Excellent attention to detail and organizational skills are a must, in addition to the ability to manage work plans on a timely basis
- Excellent computer skills to include Word, PowerPoint, Access, and Excel
- 2+ years of experience in a healthcare / managed care environment
- 1+ year experience working in Quality Improvement department
- Familiarity with NCQA regulations and HEDIS experience
- Extensive knowledge of regulatory requirements, quality improvement processes and managed care
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Clinical Quality Analyst Resume Examples & Samples
- 6+ months of experience in a managed care environment
- Access to reliable transportation that will enable you to travel to client and/or patient sites within a designated area (up to 75% travel)
- Compliance Certification (CPHQ, etc.)
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Clinical Quality Analyst Resume Examples & Samples
- Supports the development, implementation, and evaluation of performance improvement projects. Manages reports and databases used for member and provider intervention activities aimed to improve upon the AHCCCS performance standards and CMS HEDIS measures
- Develops, coordinates, provides operational management, and monitors Performance Improvement Projects (PIPs) according to AHCCCS guidelines and requirements. Collaborates with the health plans IS Department to implement valid data sources, research tools, and other data collection instruments. Actively participates in the design, implementation, application and utilization of Performance Improvement information systems in assigned focus areas. Facilitates the accuracy and completeness of clinical information used for measuring and reporting physicians performance improvement outcomes. Develops new and evaluate existing interventions through workgroups. Facilitate material development, printing, mail services and automated telephone calls through contracted vendors in compliance with current marketing guidelines and policies
- Develops, compiles, reviews, validates, preparse, and submits clinical and administrative reports required by State and National agencies. These reports may include but are not limited to: Assigned quarterly departmental reports to Quality Management / Performance Improvement Committees, EPSDT Adult Performance Quarterly Reports, annual Performance Improvement Project (PIP) reports, and Corrective Action Plans (CAP). Maintains status updates on assigned reports to facilitate ongoing evaluation and identification of opportunities for improvement
- Creates and manage datasets for Quality and Medical Management Systems and other department studies as assigned, including but not limited to setting up database and associated data entry programs, and retrieving data from the database for purposes of analysis or data review
- Requests, compiles, sorts, prepares, reviews, validates, and analyzes data extracted from Oracle Reports, ManagedCare.com, TCS, medical records and survey tools using statistically reliable sampling methods
- Utilizes IDX and / or other medical management system to validate data for initial projects and an annual review of ongoing projects ensuring the proper use of CPT, ICD-9, HCPCS, and UB Revenue codes. Conducts data analysis using Excel or SPSS software
- Serves as a front line liaison with physicians, staff, members, contracted vendors and the public concerning requests for information regarding UAHP and the Performance Improvement QM Department
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Clinical Quality Analyst Resume Examples & Samples
- Implement and maintain data bases necessary to complete standard quality reports and analysis within agreed upon deadlines surrounding the EFC CHOICES population
- Complete ad hoc reports as requested
- Routinely analyze results of quality reviews to report error trends
- Manage assigned special projects to completion within target date
- Create Quality system tools / databases to capture relevant data
- Use creativity to solve problems
- Strong clinical judgment
- Demonstrate leadership in continuous improvement
- Utilize change management to drive results
- Develop recommendations for quality remediation plans
- Share best practices and support team goals and objectives
- Drive consistency and efficient processes on the team
- Actively participate in quality improvement initiatives / meetings
- Responsible for maintaining and increasing self-proficiency in the use of quality tools and methods and the application of quality science
- Interface with many internal clinical staff and external providers to gather critical incidents information for quick turn-a-round state reporting to avoid liquidated damages
- Bachelor’s degree or higher
- 2+ years of experience working with intellectual and developmental disabilities within a Health Care or Managed Care environment ECF Choices environment
- Solid experience in tracking and trending critical incident data
- Strong computer skills including the ability to create and manipulate Excel spreadsheets
- LCSW, LBSW or LMSW within the state of Tennessee
- Experience in a Long Term Care environment
- Experience with ECF Choices
- Medical record review experience
- Knowledge of health care products, delivery systems, claims processing and supporting systems
- Knowledge of quality improvement methods and tools (SPC, Six Sigma)
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Senior Clinical Quality Analyst Resume Examples & Samples
- Assist with timely creation and completion of required monthly, quarterly and annual reports
- Medicaid managed care compliance background a plus, has to be knowledgeable or able to learn NCQA standards, HEDIS, Quality Improvement and Performance Improvement Project management
- Willing to organize meetings and write minutes as necessary
- Experience with managing policies and procedures and participating in EQRO process
- 3+ years of healthcare experience within quality or data analytics
- Intermediate computer skills (Microsoft Word, Outlook and Internet) with the ability to navigate a Windows environment. Create, edit, save and send documents utilizing Microsoft Word and Excel
- Bachelor degree, but will waive for experience
- Prior experience creating reports related to quality improvement / State, NCQA, EQRO and CMS requirements
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Senior Clinical Quality Analyst Resume Examples & Samples
- Taking minutes at Executive meetings
- Minimum of Bachelor's Degree or equivalent experience
- Ability to navigate Microsoft Access Databases, Excel and PowerPoint
- Create, edit, save and send documents utilizing Microsoft Word
- Demonstrated ability to manage multiple projects simultaneously, previous project management experience
- Must be able to work Eastern Time Zone hours
- Previous experience with quality measures such as HEDIS / NCQA
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Clinical Quality Analyst Resume Examples & Samples
- Positions in the function are responsible for end-to-end Quality Assurance process activities within UnitedHealth Care Community & State
- Working on risk identification, diagnose process issues, identify process improvement solutions and process improvement implementation using principles of process excellence and related tools
- This position will also support quality auditing, analysis, reporting and developing plans and programs
- Continuous engagement and collaboration with HEDIS team members and Health Plan Leadership is essential
- Responsible for health promotion activity plan, development and implementation
- Call center experience is essential and basic data and project management skills are also required; must be able to analyze data to improve workflow and outcomes to meet quality goals
- Undergraduate degree or equivalent experience (Working in customer service or call center environment with process improvement to improve service levels and develop staff)
- 2+ years in a role supporting a quality function developing policies or responding to state inquiries
- 2+ years of project management experience
- Intermediate experience with MS Office including Word, Excel and PowerPoint
- Intermediate level skills interpreting data and making process improvement recommendations after data analysis
- Prior experience in large, multi-function and cross geographic organizations
- Experience specifically working in an Operations Environment
- Formal Quality Training experience (ie: Six Sigma, Lean, TQM, etc)
- Knowledge base of clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements, and the managed care industry
