Clinical Quality Analyst Resume Sample
Work Experience
- Willingness to travel to the Woodlawn (Baltimore), MD facility 3-4 times per week, and as needed, to meet with federal sponsors
- The ability to retrieve, communicate and present data and information both verbally and in writing required; as is the ability to express or exchange ideas by means of the spoken and written work
- Involves discretion and independent action within prescribed limits. Frequent exposure to highly stressful situations
- Able to work at a fast pace and prioritize multiple assignments / projects and respond to numerous requests
- Able to work collaboratively with department heads, physicians, and other members of the healthcare team
- Able to concentrate and focus on projects. Possesses creative systems thinking to ensure operational efficiency. Able to problem solve and make decisions
- 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
- 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
- Work medium complexity pends
- 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
- Assist’s Optum employees to stay ahead of changing information while improving the quality and effectiveness of nurse and consumer engagement
- Ensure that process and procedural changes are reflected in staff member’s documentation such as job aids and policies
- Responsible for the data abstraction of all applicable data measures with strict adherence to the specifications manuals provided by the regulatory body
- Demonstrates applicability of methodology and reliability of definitions of the Core Measure data elements through careful monitoring of data entry into MIDAS
- Maintain current working knowledge of the changes in data definitions and variables for reporting said data measures as assigned responsibility
- Is responsible data accuracy, meeting submission timelines for all required entities as assigned by Director
- Responsible for searching external databases and web sites to keep current on all data submission requirements and specifications and using data abstraction tools to produce meaningful analyses and correlation of data
- Providing business analysis and interpretation of quality measure specifications, such as HEDIS, to technical teams in the deployment of quality measures
- Conduct Quality Assurance evaluation on clinician resource transitions within Long Term Disability claims in order to improves business processes and associate performance
- Provides timely and meaningful feedback to associates and management in regards to performance and quality standards
- Assists in developing criteria and standards in which to measure associate performance.
- Identifies and makes recommendations for process improvements or training needs
- Identify opportunities to improve the quality assurance process
- Performs internal audits, such as peer reviews, as necessary
Education
Professional Skills
- Proven experience with written and oral communication, organization, analytics, project management, and critical thinking skills
- Attention to detail, focus on customers, communication skills and analysis and problem resolution skills
- Experience utilizing problem solving and data analytical skills
- Excellent evaluative, analytical and problem - solving skills
- Project management skills – basic understanding of milestones, prioritization, escalation, and resource management
- Coding experience in a provider’s office, inpatient setting, or a Medicare Advantage health plan setting - can be combined experience
- Solid MS Excel skills including use of formulas, pivot tables, filters and basic macros
How to write Clinical Quality Analyst Resume
Clinical Quality Analyst role is responsible for excel, basic, medical, microsoft, software, analysis, analytical, database, training, integration.
To write great resume for clinical quality analyst job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Clinical Quality Analyst Resume
The section contact information is important in your clinical quality analyst resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:
- First and last name
- Telephone number
Work Experience in Your Clinical Quality Analyst Resume
The section work experience is an essential part of your clinical quality analyst resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous clinical quality analyst responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular clinical quality analyst position you're applying to.
The work experience section should be the detailed summary of your latest 3 or 4 positions.
Representative Clinical Quality Analyst resume experience can include:
- Use problem solving skills to systematically analyze problems, draw relevant conclusions, and devise appropriate courses of action
- Experience developing and implementing performance improvement projects or using data to develop intervention strategies to improve outcomes
- Clinical experience working in or managing a clinical setting (Nurse, Pharmacist, OT, clinical area manager, or similar)
- Quantitative experience including organizing and analyzing data and basic application of statistical analyses and statistical process control
- Clinical experience working in or managing a clinical setting (Nurse, Pharmacist, OT, clinical area manager or similar)
- Experience working in a medial/clinical setting
Education on a Clinical Quality Analyst Resume
Make sure to make education a priority on your clinical quality analyst resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your clinical quality analyst experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.
Additional details to include:
- School you graduated from
- Major/ minor
- Year of graduation
- Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.
Professional Skills in Clinical Quality Analyst Resume
When listing skills on your clinical quality analyst resume, remember always to be honest about your level of ability. Include the Skills section after experience.
Present the most important skills in your resume, there's a list of typical clinical quality analyst skills:
- Demonstrated ability to work independently as well as facilitate team-based change; managing multiple priorities and deadlines
- Experience reading, entering, and analyzing medical record data
- Experience collecting, analyzing and presenting data
- ) of experience in Managed Care or Primary Practice setting, including regular interaction with Providers regarding Clinical Quality Improvement
- Experience developing and implementing performance improvement projects, or using data to develop intervention strategies to improve outcomes
- Experience with creating, saving and sending documents in MS Word
List of Typical Experience For a Clinical Quality Analyst Resume
Experience For Senior Clinical Quality Analyst Resume
- Prioritizes quality and training initiatives and educational efforts to ensure urgent issues are addressed promptly and resolved
- Assisting departments with items related to case file audits e.g. creation of denial libraries
- Leads the investigation, tracking and reporting of quality of care concerns
- Work with SME / experts / clinical professionals and quality testing teams to assure accuracy of the data being brought from various sources
- Develop creative ideas for improving the testing process
Experience For Clinical Quality Analyst Senior Resume
- Assist with training and mentoring of other clinical QA
- Contacts preparer of source documents to resolve questions, inconsistencies or missing data in a courteous and professional manner
- Prepares reports and executive summaries as required by management regarding audit results, process improvement recommendations
- Documents results of all special project work and provides recommendations for opportunities and process improvement initiatives relating to special projects
- Act as clinical expert for interpretation of Verscend coding review policies and guidelines
- Data enter codes and query information into coding data base
- Coordinates the administrative review process and the reporting of critical incidents and sentinel events
- Designs appropriate communications, training, and performance support materials for internal and external stakeholders
Experience For Hedis Clinical Quality Analyst Resume
- Performs a detailed review of medical record to identify clinical indicators
- Provides face - to - face educational opportunities with physicians
- Utilizes only approved clarification forms
- Document audit findings in database and / or MS Excel
- Provides constant communication with physician when needed, per the escalation process, to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process
- Travel to facilities to perform chart reviews
- Interacts with physicians and clinical departments
- Performs data collection functions
- Uses pertinent data and facts to identify and solve a range of problems within area of expertise, health plan & employer group UM operations
Experience For Tricare Clinical Quality Analyst Senior Resume
- Investigates non-standard requests and issues with some assistance from others
- Partner with other departments to respond to client/customer requests timely and accurately
- Oversee Quality Assurance (QA) process for the monthly and quarterly submissions of customer required reports through to final report production to ensure accuracy of all data elements
- Identify, prioritize, and proactively communicate potential barriers or risks to key stakeholders. Share information across team members to increase overall team knowledge and understanding of concepts, and to ensure consistent application
- Plans, prioritizes, organizes and completes work to meet established objectives and deadlines
- Provides analytic support for responses to state inquiries and state reporting
- Development of policies and Standard Operating Procedures
- Analyzes and determines compliance with authorizations and needs identified on the service plans
- Leads special projects and committees
Experience For Lead Clinical Quality Analyst Resume
- Works directly with the Quality Manager to reviews medical charts electronically and at physician offices to abstract medical information for HEDIS (Health Employer Data and Information Set) audits, Medical Record Review, and other chart audits as assigned
- Documents all requests in appropriate systems and working with management to overcome any barriers to retrieving medical charts
- Contacts provider offices to request medical charts in support of HEDIS & other chart audits as assigned
- Interfaces with staff from across the health system (including clinical, contracting, IT, financial, legal, and operations), building collaborative relationships
- Assists with training and oversees additional chart auditor staff with auditing function
- Maintains applicable retrieval, completion and accuracy standards
- Tracks data and source documents that have been provided. Complies, sorts, interprets and verifies data to be submitted to regulatory agencies and contracted organizations
- Liaises with other key persons in health system primary care and specialty clinics and serves as a point of contact for coordinated chart audits
- Calls patients to gather procedural information and verify care delivery where necessary
Experience For Clinical Quality Analyst, Harborview Resume
- Complies with HIPAA laws and regulations associated with patient confidentiality requirements
- Mentor clinical/facility analysts (I and II) in learning and applying the rules and guidelines of coding and the application of company policies and procedures for claim review and appeals
- Contribute to various product lines by providing feedback to management and development teams on changes needed to enhance editing and efficiency. Participate on the Quality Committee as required
- Proven knowledge of facility and/or professional claims payment methodologies, payer policies and/or payer contracting along with highly-developed analytic skills with general knowledge of medical procedures, conditions, illnesses, and treatment practices
- Demonstrable knowledge of medical procedures, conditions, illnesses and treatment practices with ability to think logically and process sequentially with a high level of detailed accuracy and efficiency
- Above average personal computer skills in Microsoft Word, Excel, PowerPoint, Outlook, etc
- Conducts member outreach to provide education on care gaps and utilizes motivational interviewing techniques to encourage members to access care for needed services, coordinating scheduled visits with provider offices
- Prepares educational materials for training providers and support staff in HEDIS measures, clinical transformation practices, care gap roster management, and population management techniques
- Supports the plan in preparing member education materials, educational newsletters, and attending community events as needed
Experience For Clinical Quality Analyst, Senior Resume
- Participate in regulatory Quality Improvement Projects, implementing interventions and other monitoring activities
- Supports the plan in monitoring effectiveness of member engagement programs and provider incentive programs. Escalates feedback or trends of concern to the Health Plan Quality Director
- Assists in the evaluation of the effectiveness of the quality program
- Analyze and document test scenarios and test cases to validate the representation of data
- Continuous engagement and collaboration with QUALITY team members and Health Plan Leadership is essential
- Work with the Associate Director and Manager of Clinical Quality to create and implement 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
- Report and analyze member care quality for the development of plans and programs to support continuous quality improvement using HEDIS and other tools
Experience For Hedis Clinical Quality Analyst, Senior Resume
- Use applied analytics to forecast and trend retrospective and prospective HEDIS data
- Design, create and implement Quality Improvement HEDIS projects and initiatives
- Assume responsibility for data integrity among various internal groups and/or between internal and external stakeholders
- Remotely, review progress notes in EMR on Medicare members for (Medicare Risk Adjustment Payment System) to validate that the ICD-10 codes for the HCC (Hierarchical Conditional Categories) codes reported by the provider, are correct
- Ensure ICD-10 codes are supported by correct provider documentation before Medicare submission
- Identify any unsupported documentation in the progress notes and query the provider as necessary
Experience For Clinical Quality Analyst Resume
- Communicate appropriately to providers in writing and verbally, if required. Ability to work autonomously while achieving recommended productivity rate
- Independently use discretion and judgment to evaluate subjective clinical documentation of beneficiary records and engagements to assess performance of nursing skill
- Applies advanced knowledge to conduct multispecialty subjective assessments to evaluate the skills of nurses supporting the TRICARE – Global Nurse Advice Line (GNAL). 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, contract requirements, State regulations and Accreditation standards
- Work with colleagues across business units to ensure that process and procedural changes are reflected in staff beneficiary’s documentation such as job aids and policies
- Auditing of case files to ensure compliance with accreditation and regulatory standards and working with departments to bring case files into compliance
- Requesting improvement action plans as necessary and ensuring satisfactory completion of the IAP
Experience For Senior Clinical Quality Analyst Resume
- Assist with gathering data for routine reporting with other team beneficiary’s to be used for day-to-day purposes and at meetings
- Clearly and completely document audit findings within the audit tracking tool; including issues identified that are unacceptable areas in the workflow, staff call communication, and staff documentation performance indicating improvement is needed for discussion with management and/or at departmental team meetings
- Responsible for the management of the risk management data within the CCQAS database
- Presentation of audit findings
- Creation of audit tools
- Working with the Manager of Clinical Quality to 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
List of Typical Skills For a Clinical Quality Analyst Resume
Skills For Senior Clinical Quality Analyst Resume
- Exhibits critical thinking and problem solving skills with demonstrated role model skill in software use, computer literacy and communication/customer service
- Solid PC computer skills with proficiency in MS Office applications, especially MS Excel
- Experience managing projects, tasks, deadlines and priorities
- Excel skills (Pivot Tables, Macro’s); Ability to utilize MS Excel to collect data
- Clinical experience; or any combination of education and experience, which would provide an equivalent background
Skills For Clinical Quality Analyst Senior Resume
- Experience collecting, analyzing and presenting data
- Experience working with large work groups, running projects and gathering information necessary for audits
- Basic level of proficiency in PC - based word processing and database documentation (Word, Excel, Internet, Outlook) and experience with electronic charting
- Experience in Managed Care, including regular interaction with Providers regarding Clinical Quality Improvement
- Experience working in a medial/clinical setting
- Experience with analyzing and data modeling of medical claims, membership data, lab results or pharmacy data
Skills For Hedis Clinical Quality Analyst Resume
- Experience in interpreting technical specifications and analyzing data
- Experience working in the Medical arena
- Prior work with large databases and program testing
- Experience with Medicare and CMS reporting
- Experience working as behavioral health clinician
- Experience utilizing platforms such as Linx, ICUE, ISET
- Experience developing written communications for business protocols
Skills For Tricare Clinical Quality Analyst Senior Resume
- Experience with data extraction and reporting
- ) experience in clinical setting or Federally Qualified Health Center
- Experience working in Quality Improvement department highly
- Experience within a health care and/or behavioral health setting
- Experience in a managed care setting with responsibility for URAC, NCQA (UM, PBM, DTM, etc.)
- Experience working with Medicare/Medicaid
- Auditing or medical record experience
- Experience creating reports related to quality improvement / performance outcomes
Skills For Lead Clinical Quality Analyst Resume
- Experience leading functional or segment teams or projects
- Experience working with clinical survey or process improvement initiatives
- Experience in data and/or financial analysis
- Experience as a Registered Nurse
- Data analysis experience
Skills For Clinical Quality Analyst, Harborview Resume
- Healthcare experience focused on adherence or compliance in Utilization Management
- Experience within a matrix organization, healthcare or insurance company
- Self-starter - able to independently, drive work and prioritize work with minimal oversight
- Experience with Medicaid waivers
- Skilled user of Microsoft Excel (analysis of data) and Microsoft Word
- Experience with project and/or product management lifecycles
- Working knowledge of administrative claims data and medical coding systems (i.e. CPT, HCPCS, ICD - 9, NDC)
- Understanding of the quality measurement marketplace (i.e. NCQA - HEDIS, NQF, CMS) and how their tools are used in healthcare
Skills For Clinical Quality Analyst, Senior Resume
- Understanding of clinical taxonomies (ICD10, CPT, LOINC, NDC, SNOMED, etc.)
- Traveling to conduct on-site provider audits throughout Virginia
- Assists in planning, organizing, directing and implementing a means of collecting clinical decision support information for Methodist Healthcare
- Advanced level of Microsoft Excel (proficiency with reporting, sorting, filtering and formulas)
- Maintain and adhere to reporting schedule and schedule meetings as necessary to coordinate resources responsible for supporting the reporting process
- Exposure to requesting reports/ managing creation of reports, participation in IT projects, etc
- Proficiency using a PC in a Windows environment, including Microsoft Word
Skills For Hedis Clinical Quality Analyst, Senior Resume
- Conducts constant follow - up communication with providers regarding existing clarifications to obtain needed documentation specificity
- Perform clinical quality assurance review of daily claims editing reviews and appeals and provide feedback/training to improve quality and accuracy
- Capable of working independently and collaboratively with other members of the team
- Knowledge of one or more of: clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements
- Familiar with regulatory and accreditation agencies and their QI requirements, including CMS (Medicaid/Medicare), HEDIS and NCQA/URAC
- Conducts new hire orientation and on-the-job training sessions
- Conducts provider on-site audits researching provider clinical quality issues
- Performs chart reviews in accordance guidelines with ICD - 10 - CM Official Guidelines and Optum Coding Guidelines
- Track system/platform enhancements for bundling into IT Projects and participate as a SME through implementation
Skills For Clinical Quality Analyst Resume
- Excellent verbal communication, interpersonal and customer service skills, necessary when working with civilian Medical Staff Services offices and military providers
- Proficient user of Microsoft Office tool Suite, to include Access
- Proficient at healthcare research
- Exposure to project and / or product management and lifecycles
- RHIA, RHIT, CCS, CPC, CPC-H Certification
- Work independently in a fast - paced environment with minimal supervision and guidance
- Interpersonal Skills - ability to deal and work with people with different leadership levels and backgrounds. Demonstrated ability to build and maintain long term internal business relationships
Skills For Senior Clinical Quality Analyst Resume
- Current unrestricted RN licensure in the State of Hawaii
- Travel to physician offices locally up to 75% of the time in Sacramento County
- Travel to physician offices locally up to 75% of the time in San Diego County
- Current unrestricted RN licensure in the State of California
- Familiarity with NCQA regulations
- Work experience in a managed care, hospital, provider practice or other comparable business experience, preferably in a quality/performance improvement setting
List of Typical Responsibilities For a Clinical Quality Analyst Resume
Responsibilities For Senior Clinical Quality Analyst Resume
- Intermediate Microsoft Excel skills and experience
- Prior experience with HEDIS
- Prior State Medicaid experience
- Experience in Medical Coding
- Experience using EMR systems
- Ensures effective internal communication of Quality Data requirements and results
Responsibilities For Clinical Quality Analyst Senior Resume
- Experience in healthcare industry
- Prior with Health Insurance industry
- Experience in a healthcare/managed care environment
- Skilled in MS Word, Outlook and Excel
- 3+years of RN experience
- Specialty license and experience in Women’s Health, Oncology and/or Behavioral Health
- Clinical audit experience (preferably sales and customer service)
- Clinical Contact Center experience
- Previous audit/chart review experience
Responsibilities For Hedis Clinical Quality Analyst Resume
- Experience in a healthcare / managed care environment
- Project management, quality management, and process improvement experience
- Successful completion of one of the following coding certificate programs RHIA, RHIT, CCS, CCS-P, or CPC-H status
- Assists committees and project teams in identifying performance issues
- Develop and maintain training modules for accredited areas
- Review cases selected for client audits; conduct mock audits, coaching staff on case presentations
Responsibilities For Tricare Clinical Quality Analyst Senior Resume
- Facilitate and attend the onsite accreditation survey and any onsite monitoring visits
- Works with medical directors on cases involving signification deviation from standard practice
- Supports the QAPI program’s initiatives, member safety activities and committee structure
- Generates solutions for identified problem areas and drives action plans to maintain compliance with contract requirements
- Assists in the development of new quality initiatives
- Prepares quality assurance and committee reports
- Ensures policy and procedure compliance
- Participates in internal quality assurance audits
- Collaborates across divisional teams to promote timely and efficient resolution of member case reviews
Responsibilities For Lead Clinical Quality Analyst Resume
- Assists in the coordination of and collaboration between established quality committees
- Reports on the status of quality projects for senior management
- Assess the representation of data, in the UI, from a clinical perspective
- Identify potential misrepresentation of data/information, and triage these findings
- Analyze and understand the data sources for the respective datasets - Rx Claims, Lab, Medical Claims, CDA, EMR, etc
- Analyze and understand the characteristics of the data and information, as it is displayed in the UI
- Work independently and with other QA team members
- Stay up-to-date on new features, improvements and versions
Responsibilities For Clinical Quality Analyst, Harborview Resume
- Provide quick turn-around on analysis of issues identified
- Compare and contrast data between system builds / code updates
- Ensures organizational compliance with regulatory, registry, and internal quality data collection and submission requirements for the Quality Performance and Patient Safety Department
- Develops strategies to successful analyze data, assist decision support, and provide end user reports with information including limitations of data and actionable information
- Provides project management and analytic expertise for initiatives which support organizational performance in Clinical Process Measures, Outcomes Measures, Efficiency Measures, Electronic Clinical Quality Measures, and Patient Engagement Measures
- Evaluates own overall area of responsibility and develops personal achievement goals which align with department and organizational strategic priorities
- Resource expert for NCQA and/or URAC standards and their interpretation
- Complete on-line applications, maintenance attestations, and organizational change notifications
- Proactively identify and communicate accreditation risks and potential barriers to the functional areas; assist functional areas with the development of action plans to address risks and/or barriers
Responsibilities For Clinical Quality Analyst, Senior Resume
- Interact collaboratively with Clinical Operations and Product Directors and staff to ensure continuous accreditation compliance
- Act as Subject Matter Expert (SME) in the development and documentation of Quality Improvement Projects (QIPs) for URAC, Quality Improvement Activities (QIAs) for NCQA, and Performance Measures (PMs) for URAC
- Identify business leads and Subject Matter Experts to participate in audits/assessments
- Lead meetings with business leads and Subject Matter Experts to prepare for accreditations and/or client audits
- Obtain pertinent audit documents from Subject Matter Experts
- Lead the site preparation for accreditations and/or client audits
Responsibilities For Hedis Clinical Quality Analyst, Senior Resume
- Take minutes at Executive meetings
- Read and interpret standards/requirements and technical specifications (e.g., structure and process, CMS star ratings, NCQA/HEDIS/CAHPS) in order to develop and/or run data queries
- Works on issues of diverse scope in which the analysis of data requires evaluation of identifiable factors and in accordance with department standards
- Develops and monitors corrective actions
- Completes quarterly progress/performance reports
Responsibilities For Clinical Quality Analyst Resume
- Maintains quality database via requests for information and questionnaires
- Reviews clinical quality of care grievance cases to help determine whether issues exist, and to what extend
- Works on more complex studies in which analysis of situations or data requires an in-depth evaluation of various factors
- Completes quarterly progress/performance reports and/or participates in quarterly presentations to internal and/or regulatory audiences
- Provides feedback to practitioners, medical directors, and grievance analysts on identified performance issues
- Prepares department for oversight audits
Responsibilities For Senior Clinical Quality Analyst Resume
- Prepares corrective action plans in response to oversight body's request
- Writes policies and procedures
- Assists with development of provider manuals, audit tools, and guidelines
- Coordinates collection and organization of information and documents in preparation for regulatory audits
- Participates in development and design of audit tools, policies and procedures, and provider manuals
- Provides feedback to practitioners on performance