Clinical Readmission Review Quality Analyst

This is a fully remote position, open to applicants in United States.

📋 Description

• Utilize clinical judgment and expertise in readmission review to ensure the precision and uniformity of completed Clinical Readmission Review audits.

• Conduct quality assessments of both random and targeted samples of work performed by Clinical Readmission Review Auditors.

• Confirm findings, no-findings, clinical justifications, and accompanying documentation.

• Adhere to the approved sampling methodology for random, targeted, and follow-up quality assessments.

• Implement established quality scoring criteria to assess audit accuracy, documentation quality, and compliance with program expectations.

• Ensure that readmission determinations are substantiated by medical records, clinical criteria, client specifications, and internal protocols.

• Examine audit documentation for clarity, completeness, grammatical accuracy, evidence-based support, and alignment with quality standards.

• Offer constructive feedback and coaching to Clinical Readmission Review Auditors.

• Recognize audit trends, missed opportunities, recurring mistakes, and potential cases for further review or escalation.

• Conduct root cause analysis and propose corrective measures.

• Facilitate calibration discussions, quality monitoring, updates to standard operating procedures, and training initiatives.

• Compose professional communications that detail quality review outcomes, findings, rationales, error trends, and suggested next steps.

• Maintain records of quality review outcomes and reporting for performance monitoring, trend analysis, and leadership evaluation.

• Relay quality results, obstacles, trends, and improvement suggestions to colleagues and management.

• Undertake additional duties as required.

• Carry out responsibilities in alignment with company compliance, information security, HIPAA, regulatory policies, procedures, and programs.

⛳️ Requirements

• Registered Nurse certification is mandatory.

• An Associate’s or Bachelor’s degree is essential.

• A current, unrestricted RN license in the United States is required.

• A minimum of 5 years of experience in acute care nursing, utilization review, clinical auditing, readmission review, quality review, or related healthcare fields is preferred.

• Previous experience in readmission review, potentially preventable readmissions, quality control, secondary review, peer review, audit validation, or clinical audit quality monitoring is preferred.

• Familiarity with potentially preventable readmission concepts, readmission drivers, discharge planning, transitions of care, and medical necessity is preferred.

• Comprehensive knowledge of inpatient medical record reviews, discharge planning, readmission drivers, medical necessity, transitions of care, and documentation requirements.

• Ability to synthesize complex inpatient medical record documentation, identify quality errors or missed opportunities, and make objective, evidence-based quality assessments.

• Exceptional written and verbal communication abilities.

• Strong analytical skills and meticulous attention to detail.

• Capability to provide professional feedback.

• Proficiency in Excel, Word, Outlook, OneNote, and general computer applications.

• Ability to work autonomously in a remote setting and achieve results during EXL's core business hours.

• Knowledge of HIPAA compliance.

🏝️ Benefits

• Fully remote, U.S.-based work opportunity.

• Up to 10% annual travel.

• Benefits information available through EXL’s U.S. careers and benefits page.