POSITION OVERVIEW:

The USRN Quality Assurance Analyst is responsible for evaluating clinical transactions, documentation accuracy,
and adherence to U.S. healthcare guidelines to ensure high-quality service delivery. The role conducts audits of medical reviews, clinical calls, prior authorization assessments, case management activities, and other USRN-related workflows. This position ensures compliance with client requirements, U.S. healthcare standards (e.g., MCG, InterQual), HIPAA regulations, and internal policies. The USRN QA Analyst is instrumental in identifying performance gaps and supporting continuous improvement initiatives that enhance clinical accuracy, compliance, and operational excellence.

Key Responsibilities :

A. Clinical Quality Monitoring & Evaluation
 Conduct clinical audits of nurse reviews, including:
o Utilization Management (UM) assessments
o Case Management (CM) interventions
o Clinical Triage calls
o Medical necessity determinations
o Clinical documentation and rationale
 Validate adherence to established guidelines such as MCG/Milliman, InterQual, CMS regulations, and client-specific criteria.
 Ensure accuracy of ICD/CPT usage (where applicable), medical necessity validation, and level-of-care appropriateness.
 Review documentation for completeness, clarity, and clinical compliance.

B. Feedback Delivery & Coaching Support
 Provide structured, objective, and timely feedback to nurses based on audit findings.
 Participate in one-on-one coaching sessions with Operations Leaders, Trainers, and Clinical SMEs.
 Recommend corrective actions, additional training, or skill-building interventions.
 Reinforce proper clinical reasoning, documentation standards, and U.S. healthcare protocols.

C. Reporting & Performance Analytics:
 Prepare clinical quality reports, evaluation summaries, error trending analyses, and calibration results.
 Identify patterns of errors related to clinical decisions, documentation, guidelines usage, and workflow adherence.
 Collaborate with Training and Operations to address systemic issues and implement improvement plans.
 Support root-cause analysis (RCA) activities for recurring or critical quality concerns.

D. Compliance & Regulatory Adherence
 Ensure strict compliance with HIPAA, client data privacy requirements, and clinical documentation standards.
 Participate in calibration sessions with clients, QA teams, and clinical leadership to align evaluation criteria.
 Support internal and external audits as required.
 Uphold organizational confidentiality standards at all times.

E. Process Improvement
 Provide recommendations to enhance quality evaluation tools, audit forms, and clinical criteria reference materials.
 Assist in developing or improving clinical workflows, SOPs, and documentation guidelines.
 Support upskill, refresher, and continuous learning programs for clinical teams.
 Participate in clinical quality projects and improvement initiatives.

Non-Negotiable Requirements:

• PH Registered Nurse
• Registered Nurse with current, unrestricted US Registered Nurse license w/ BPO Experience and QA Experience
• Minimum 2 years of clinical bedside experience (ER, ICU, Med-Surg, Telemetry preferred).
• Minimum 1 year of USRN BPO or U.S. Healthcare experience in UM, CM, Appeals, Triage, or related clinical processes.
• Knowledge of MCG/Milliman, InterQual, clinical guidelines, HIPAA requirements, and U.S. medical terminology.
• Prior experience as a Quality Analyst, Clinical Auditor, or Clinical Reviewer in a U.S. healthcare account.
• Strong analytical skills with high attention to detail and documentation accuracy.
• At least one (1) year of experience in medical accounts for clerical or administrative support; someone experienced in handling or reviewing medical data or documentation
• Excellent English communication skills both verbal and written; must be comfortable in taking phone calls and high-volume emails.
• Ability to stay focused and adaptable under pressure and shifting priorities
• Knowledgeable in US Healthcare Law and Care Coordination
• Familiarity with coding systems (ICD-10, CPT) is a plus.
• Strong proficiency in MS Office tools and QA evaluation systems."