PHRN Clinical Quality Evaluator (Medical Coding Certified)

Responsible for evaluating the quality of services and interactions provided by organizations within the enterprise.

Primary duties may include, but are not limited to:

• Evaluates the quality and accuracy of transactions and/or communications with providers, groups, and/or policyholders.
• Identifies, documents, and reports any transaction errors or communications issues in a timely manner to ensure prompt resolution.
• Tracks and trends audit results, providing feedback to management.
• Conduct calibration sessions to evaluate and ensure that all teams are aligned with the set QA guidelines.
• Identifies and reports on systemic issues which create ongoing quality concerns.
• Conducts root cause analysis to determine the underlying causes of noted quality opportunities using the RCA tools.
• Recommend, implement, and monitor preventive and corrective actions to ensure that quality standards are achieved.
• Generates monthly r...