• Job Description

  Req#: CLINI001050
  Clinical Quality Assurance Analyst
  
  This Position is remote and requires CPC, CRC, or equivalent coding certification credential.
  
  We are more than just a healthcare company; we are a community of professionals driven by the knowledge that our success leads to a positive impact on the communities that we support.
  
  At ComplexCare Solutions, you'll play a crucial part in innovating solutions that empower health plan members and healthcare providers alike. Our collaborative environment fosters creativity and initiative, ensuring that every idea and effort contributes to meaningful change in the industry. Join us and become a part of a team that turns vision into action, making a tangible impact on the future of healthcare.
  
  Overview: The Clinical Quality Assurance Analyst is responsible for auditing, training, and collaboration to support quality standards in clinical data and reporting. This position is also responsible for ensuring appropriate understanding and maintenance of clinical data and reporting across the enterprise.
  
  Duties and Responsibilities:
  
  • Demonstrate and maintain an expert level of knowledge regarding ComplexCare Solutions (CCS) clinical chart review and auditing from a clinical data extract standpoint and affiliate services.
  • Maintains comprehensive and up-to-date knowledge of current issues, emerging trends, and regulatory changes impacting medical record coding and documentation, particularly those governed by the Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG). Applies this knowledge to support compliance, mitigate risk, and promote accurate, ethical coding and documentation practices across the organization.
  • Assist with the development, organization, and implementation of companywide quality improvement efforts.
  • Maintain the control and ongoing monitoring of quality and reliability as well as quality reporting mechanisms and management tools.
  • Perform analysis of reviews and lead consolidation of findings for reporting to senior leadership and other key stakeholders.
  • Ensure compliance with contractual, local, state and national quality standards.
  • Support current and future clinical product strategy through competitive research analysis, peer-group comparisons, product and clinical research and development, human resource requirements, and market opportunity analysis.
  • Support clinical product implementations to include facilitation of ensuring designated clinical projects and their respective stage of development is met on time, on budget, and according to written requirement specifications.
  • Assist with the development and successful execution of CCS's training processes (both initial and ongoing training) for review personnel.
  • Maintain open lines of communication with key stakeholders.
  • Make recommendations for process and technical changes; document changes as applicable.
  • Assist in the development and execution and management of internal and client facing clinical auditing programs.
  • Assist with client relationships across the Company's quality management services while also supporting, nurturing, and expanding successful client relationships.
  • Support organization's cross functional teams using exceptional clinical and business skills.
  • Maintain compliance with CCS's policies, procedures, mission, and goals.
  • Adhere to all confidentiality and HIPAA requirements as outlined within CCS's Operating Policies and Procedures in all ways and at all times with respect to any aspect of the data handled or services rendered in the undertaking of the position.
  • Fulfill those responsibilities and/or duties that may be reasonably provided by CCS for the purpose of achieving operational and financial success of the Employer.
  
  Job Requirements:
  
  • Minimum of two (2) years of hands-on HCC auditing experience required; RN coder preferred.
  • Minimum of two (2) years of clinical nursing experience preferred.
  • Minimum of four (4) years of experience in healthcare plan quality improvement initiatives. preferred.
  • Minimum of three (3) years of experience with public programs (e.g., Medicare, Medicaid) highly preferred.
  • Excellent analytical skills, with the ability to understand the company's products and processes.
  • Strong organizational skills.
  • Exceptional clinical skills required.
  • Advanced computer proficiency in Microsoft Office products to support all CCS care management programs.
  
  Education:
  
  • Active CPC, CRC, or equivalent coding credential required.
  • Bachelor's degree in Nursing (BSN) preferred.
  
  Compensation:
  
  • Salary Range: $65,100 - $97,700
  
  The company offers competitive compensation and an excellent benefits package.
  
  The Company is proud to be an equal opportunity workplace and is an affirmative action employer. We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity, veteran status, or any other protected characteristic under federal, state, or other applicable laws.
  
  This company utilizes E-Verify
  
  Equal Opportunity Employer
  This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.

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