Quality Analyst (Clinical Claims)

The Quality Analyst is responsible for monitoring, evaluating, and improving the quality of clinical claim operations within an AO Clinical Claim Program. This role ensures that claims reviews, medical documentation assessments, customer interactions, and operational processes meet client requirements, regulatory standards, and internal quality expectations. The Quality Analyst partners closely with Operations, Training, and Clinical Teams to identify improvement opportunities, provide actionable feedback, and drive continuous quality excellence.

Key Responsibilities

Quality Monitoring & Evaluation

• Conduct regular audits of clinical claim reviews and related transactions.
• Evaluate adherence to client guidelines, operational procedures, and quality standards.
• Assess documentation accuracy, completeness, and compliance with established workflows.
• Ensure consistency in claim review decisions and quality outcomes.

Reporting & Analysis

• Maintain quality scorecards and audit documentation.
• Analyze quality trends, root causes, and performance gaps.
• Prepare and present quality reports to Operations leaders and stakeholders.
• Recommend corrective and preventive actions based on audit findings.

Coaching & Feedback

• Provide timely and constructive feedback to Clinical Claims Associates and Nurses.
• Partner with Team Managers in developing performance improvement plans.
• Support calibration sessions to ensure scoring consistency among quality evaluators.
• Identify learning opportunities and collaborate with Training teams.

Compliance & Process Excellence

• Ensure compliance with HIPAA, client policies, applicable healthcare regulations, and internal standards.
• Participate in process improvement initiatives to enhance quality, productivity, and customer experience.
• Support implementation of quality frameworks and continuous improvement programs.
• Escalate critical quality and compliance issues appropriately.

Stakeholder Management

• Collaborate with Operations, Training, Workforce Management, and Client Services teams.
• Participate in client calibrations and quality discussions as needed.
• Contribute to business reviews and quality governance activities.

Required Qualifications

• Active and unrestricted US Registered Nurse (USRN) license.
• Minimum 2 years of recent clinical experience in hospital, utilization management, case management, disability, health insurance, or related healthcare settings.
• At least 1 year of Quality Analyst experience in a BPO, healthcare, insurance, claims, or clinical operations environment.
• Strong understanding of healthcare documentation, claim review processes, and medical terminology.
• Knowledge of quality methodologies, auditing principles, and root cause analysis.
• Excellent analytical, coaching, and communication skills.
• Experience in performance monitoring, quality scorecards, and reporting.
• Proficiency in Microsoft Office applications, particularly Excel and PowerPoint.
• Ability to work independently and manage multiple priorities in a fast-paced environment.

Preferred Qualifications

• Experience supporting Disability Claims, Clinical Claims, Group Benefits, or Insurance Operations accounts.
• Knowledge of disability management or absence management programs.
• Experience handling quality calibrations and client-facing quality reviews.
• Lean Six Sigma Yellow Belt or equivalent quality certification.
• Experience using quality management systems and reporting tools.

Internal Qualifications

• Must have Annual PDP score of Exceeds Expectations (4) or Outstanding (5)
• Tenure of at least 12 months on the current role
• No Active DA