PHRN Clinical Quality Evaluator (Medical Coding Certified)

Full-time PRB

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 ...