Role Overview
As a Quality Analyst, you will evaluate medical records and treatment plans to ensure services are clinically appropriate and align with established standards. Your work will directly support efficient healthcare delivery by verifying medical necessity, care quality, and regulatory compliance.
Key Responsibilities
- Review patient documentation to assess the appropriateness and medical necessity of treatments using recognized guidelines such as InterQual, Milliman, CMS, or health plan-specific criteria.
- Analyze clinical data to confirm that care meets quality benchmarks and regulatory requirements, including URAC and state-specific standards.
- Apply clinical judgment to interpret evidence-based protocols and determine proper service authorization.
- Collaborate with physicians, care teams, and leadership to support sound clinical decisions and improve patient outcomes.
- Enter and manage clinical information in medical management systems with accuracy and timeliness.
- Act as a clinical resource for non-clinical staff, providing guidance on medical content and care coordination.
- Support process improvements to reduce report revisions, enhance peer-to-peer communication, and improve client satisfaction.
- Finalize case reviews for client submission and coordinate quality-related reports with senior clinical leadership.
- May supervise or guide team members as operational needs evolve.
Qualifications
- Active, unrestricted LPN or RN license from an accredited program.
- Minimum of two years of hands-on clinical nursing experience.
- At least one year of experience in Utilization Management or a related clinical review function.
- Strong written and verbal communication skills, with the ability to interact professionally with providers and stakeholders.
- Proficiency in Microsoft Office applications including Word, Excel, Access, PowerPoint, and Outlook.
- Experience with internet-based systems and medical management platforms.
- Ability to adapt to changing software, systems, and workflows.
- Highly organized with sharp attention to detail and the capacity to manage multiple priorities in a fast-paced setting.
- Reliable internet connection and personal capability to support remote work infrastructure.
Work Environment
This is a fully remote position with defined shift availability. Candidates must be available during one of the following windows: Sunday–Thursday (8 AM–4:30 PM EST), Monday–Friday (7 AM–3:30 PM EST), or Tuesday–Saturday (9 AM–5:30 PM EST). The role requires consistent connectivity and self-sufficiency in maintaining a productive home workspace.
Compensation and Benefits
- Competitive salary range of $45,000 to $70,000 USD, with eligibility for performance-based bonuses.
- 401(k) plan with company matching contributions.
- Comprehensive medical, dental, and vision insurance for employees and dependents.
- No-cost coverage for basic life insurance, short-term and long-term disability.
- Optional supplemental plans including critical illness, accident indemnity, hospital indemnity, voluntary life insurance, and pet insurance.
- Generous paid time off policy.
- Company-provided Apple equipment and a media stipend to support remote work setup.
Culture and Values
The organization fosters a high-performance environment rooted in fairness, inclusion, and competitive compensation. Diversity is actively supported, and efforts are continuously made to ensure an equitable and welcoming workplace for all team members.
