Clinical Readmission Review Quality Analyst

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

📋 Description

• Supervise the activities conducted by Clinical Readmission Review Auditors

• Conduct quality assessments of both random and targeted samples of finalized readmission audits

• Verify findings, non-findings, clinical justifications, and accompanying documentation

• Adhere to approved sampling methods for random, targeted, and follow-up quality evaluations

• Utilize quality scoring criteria to assess audit accuracy, documentation quality, and compliance with program standards

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

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

• Offer constructive feedback and coaching assistance to auditors

• Detect audit patterns, missed chances, recurring mistakes, and potential referrals for further review or escalation

• Conduct root cause analysis and propose corrective measures

• Assist in calibration discussions, quality monitoring, procedure revisions, and training opportunities

• Document quality review outcomes, audit results, supporting rationales, error patterns, and suggested next actions

• Preserve quality review results and reporting for performance oversight, trend analysis, and leadership evaluation

• Share quality results, obstacles, trends, and improvement suggestions with colleagues and management

• Comply with company policies on compliance, information security, HIPAA, and regulatory standards

⛳️ Requirements

• Registered Nurse with an Associate’s or Bachelor’s degree is mandatory

• An active, unrestricted RN license in the United States is required

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

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

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

• Strong understanding of inpatient medical record review, discharge planning, readmission drivers, medical necessity, transitions of care, and documentation requirements

• Capability to synthesize complex inpatient medical record documentation and make objective, evidence-based quality assessments

• Outstanding written and verbal communication abilities, analytical skills, attention to detail, and capacity to provide professional feedback

• Proficient in Excel, Word, Outlook, OneNote, and general computer applications

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

• Knowledge in Clinical Readmission Review, Quality Control Review, Audit Sampling, Medical Record Review, Clinical Judgment, Potentially Preventable Readmissions, Root Cause Analysis, Quality Feedback, Calibration, Trend Identification, Written Communication, and HIPAA Compliance

🏝️ Benefits

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

• Up to 10% annual travel requirement

• Detailed benefits information available at https://www.exlservice.com/us-careers-and-benefits