CLINICAL QUALITY ANALYST JOB DESCRIPTION

A Clinical Quality Analyst is someone who reads clinical documentation and turns it into a verdict on whether care is being delivered right. The role sits inside managed care or care management operations, answering to program directors while producing findings that shape training, compliance posture, and provider accountability. Medicaid Managed Care and NCQA accreditation standards define the rules this analyst enforces - two regulatory frameworks that demand consistent interpretation across hundreds of case records. No other reviewer in the department carries both the clinical judgment to evaluate Person-Centered Plans and the analytical scope to trend findings across a provider network.

As the Clinical Quality Analyst, you audit clinical documentation, investigate care management interventions, and surface compliance risks before they reach regulators or accrediting bodies. Your findings travel directly to Directors and Supervisors, giving leadership the evidence base for performance decisions and training priorities across the care management program.

Career Impact: Sustained work under NCQA and CMS frameworks builds a compliance and clinical audit credential that is recognized by managed care organizations, health plans, and state Medicaid agencies - a durable foundation for senior quality or compliance roles.

Business Impact: When care documentation gaps go undetected, NCQA accreditation and Medicaid contract standing are both at risk; this role is the mechanism that catches those gaps before they become reportable events.

Growth Opportunity: Mastery of inter-rater reliability methods, root cause analysis, and HEDIS-aligned reporting positions analysts to move into Quality Manager or Clinical Compliance Director tracks within three to five years.

• Audit Care Management clinical documentation and case interventions to verify alignment with NCQA guidelines, CMS requirements, and evidence-based clinical standards.
• Review Person-Centered Plans and chart notes for procedural accuracy and adherence to program workflows.
• Conduct quality of care investigations for behavioral health and substance use disorder providers.
• Identify and escalate compliance, quality, and safety risks that could adversely affect program operations or regulatory standing.
• Generate monthly quality performance reports and deliver written findings to Directors, Managers, and Supervisors.
• Evaluate clinical appropriateness of care decisions within documented interventions and flag deviations for corrective action.
• Assess staff knowledge gaps in collaboration with Care Management Leadership to coordinate targeted training opportunities.
• Monitor training outcomes to measure effectiveness and document improvement in performance metrics.

• Bachelor's degree in a health-related field, nursing, social work, or equivalent clinical work experience.
• 3 or more years of care management or behavioral health quality review experience, with direct exposure to Medicaid Managed Care programs.
• Active, unrestricted independent clinical licensure (LP, LCSW, LMFT, LPC, or RN) preferred or required depending on employer.
• Knowledge of NCQA accreditation standards and CMS regulatory requirements governing managed care programs.
• Demonstrated ability to conduct clinical audits, analyze documentation, and produce written findings for leadership audiences.
• Experience with integrated care models spanning behavioral health and physical health service delivery.
• Strong written communication skills sufficient to draft regulatory responses, audit reports, and staff feedback.
• Analytical proficiency in interpreting qualitative and quantitative data to identify trends and support root cause analysis.

• Familiarity with HEDIS measurement standards and their application to care management performance reporting.
• Knowledge of Tailored Plan requirements or state-specific Medicaid service continuum regulations.
• Experience applying inter-rater reliability protocols to standardize audit findings across a quality review team.
• Graduate degree in public health, nursing, or behavioral health, or a certification in healthcare quality such as CPHQ.

• Audit completion rate, measured as percentage of assigned case records reviewed per reporting cycle.
• Finding accuracy rate, tracking inter-rater reliability scores against benchmark thresholds established by the program.
• Escalation response time, measuring days between risk identification and formal notification to supervisors.
• NCQA readiness score, reflecting the proportion of audited records meeting accreditation documentation standards.
• Training impact rate, comparing staff performance metrics before and after recommended interventions are implemented.
• Typical tools: Clinical documentation platforms (commonly electronic health record systems); data analysis applications (commonly spreadsheet and statistical software); survey and reporting tools (commonly online survey platforms and database reporting tools).

• Base Salary Range: $62,000 to $88,000 annually, varying by licensure, seniority, and geography.
• Bonus: Annual performance bonus of 5 to 10 percent, tied to audit output and compliance metrics.
• Equity: Typically not offered in managed care or nonprofit healthcare settings.
• Health Benefits: Medical, dental, and vision coverage; employer contribution varies by organization size.
• PTO: 15 to 20 days annually, plus standard federal holidays and sick leave.
• Common Perks: Remote or hybrid flexibility, continuing education reimbursement, licensure renewal support.

Figures are estimates based on general US market benchmarks and may be outdated. Adjust based on location, company size, and seniority level.

Background check clearance, including criminal history review and applicable drug screening, is required as a condition of employment in this clinical environment. All applicants are evaluated without regard to race, color, religion, sex, national origin, age, disability, veteran status, or any other characteristic protected under applicable federal, state, or local law. Reasonable accommodations for individuals with disabilities are available throughout the hiring process upon request. Candidates must hold valid authorization to work in the United States prior to the start of employment.

The Clinical Quality Analyst owns the quality review process for care management programs, auditing clinical documentation, Person-Centered Plans, and staff performance data against NCQA, CMS, and regulatory guidelines to surface compliance risks and drive improvement. Reporting to Directors and Managers, this role delivers monthly quality reports, escalates safety and compliance concerns, and collaborates with Care Management Leadership to identify training gaps and monitor the impact of corrective interventions.

Key Responsibilities

• Review the quality of Care Management internal processes, plans, and provider information, such as Person-Centered Plans or chart notes, for alignment with procedures and best practices.
• Audit Care Management clinical documentation, case interventions, and staff phone recordings to ensure alignment with program descriptions, workflows, internal policies, evidence-based clinical guidelines, NCQA guidelines, CMS guidelines, and regulatory guidelines.
• Identify and escalate situations that may pose quality, compliance, and safety risks adversely affecting business operations.
• Evaluate clinical appropriateness of decisions, recommendations, and actions within Care Management documentation.
• Interpret qualitative and quantitative information to appropriately document findings.
• Make recommendations for improvement related to any records reviewed.
• Write reports of findings.
• Identify system and operational issues hindering the attainment of quality performance standards as defined by NCQA standards and applicable state and federal laws and regulations.
• Generate monthly Care Management Quality reports on staff performance for submission to Directors, Managers, and Supervisors.
• Provide written feedback to Directors, Managers, and Supervisors concerning quality concerns related to individual performance, compliance risks, trends, root cause analysis, and recommended system or process improvements.
• Evaluate knowledge gaps of staff and collaborate with Care Management Leadership to coordinate learning and training opportunities with the Care Management Training team.
• Monitor training of staff for effectiveness and impact of outcomes from enhanced training.

Required Qualifications

• Experience with care plans, comprehensive assessments, care management interventions, and service engagement activities.
• Experience with Medicaid Managed Care.
• Experience with integrated care covering behavioral and physical health.
• Knowledge of state and federal rules and requirements related to the service continuum.
• Knowledge of Tailored Plan, Integrated Care, and Care Management processes and regulatory requirements.
• Knowledge of best and promising practices for behavioral and physical health and intellectual and developmental disabilities.
• Proficient in Microsoft Excel, Word, PowerPoint, SPSS, and online survey tools.
• Strong clinical skills.
• Strong analytical and problem-solving skills.
• Strong conflict resolution and diplomacy skills with a high level of discretion.
• Highly effective written and verbal communication skills.
• Ability to negotiate and resolve issues with minimal assistance.
• Strong interpersonal skills.

Embedded within a behavioral health quality team, the Sr. Clinical Quality Analyst delivers clinical audits and quality of care investigations of behavioral health and substance use disorder providers, applying inter-rater reliability standards and extracting data from SQL or Oracle environments to support monitoring activities. Working closely with program leadership and external providers, this role advances compliance with Medicaid service delivery requirements and Joint Commission and HEDIS standards through rigorous record review and analytical reporting.

Core Functions

• Complete clinical audits and record reviews of behavioral health and substance use disorder providers.
• Provide education and support to providers regarding operational and treatment record documentation standards.
• Conduct quality of care investigations of behavioral health and substance use disorder providers.
• Provide analytical support and expertise when compiling report information.
• Develop and implement effective analysis, research, and evaluation in preparation for clinical monitoring audit activities.
• Assume responsibility for inter-rater reliability of clinical audit activities.
• Extract appropriate data from SQL or Oracle environments.
• Participate in departmental meetings and activities.

Qualifications & Experience

• Master's degree or Ph.D. leading to an independent behavioral health licensure.
• Active, unrestricted, independent mental health licensure such as LP, LCSW, LMFT, or LPC.
• 3+ years of experience with behavioral health.
• Experience with conducting clinical audits of behavioral health and substance use disorder treatment records.
• Experience with Medicaid service delivery.
• Knowledge of Joint Commission survey processes.
• Knowledge of HEDIS Standards.
• Knowledge and experience with behavioral health evidence-based practices.
• Intermediate proficiency in Microsoft Word, Excel, Outlook, and Internet with the ability to navigate a Windows environment including creating, editing, saving, and sending documents.
• Demonstrated ability to collect, analyze, and present data.
• Access to high-speed internet and a dedicated, distraction-free workspace at home.
• Required to perform this role with providers on site when travelling and working on-site, as this is an essential function of this role.
• Provisioned with appropriate Personal Protective Equipment when working on-site.

Reporting to Corporate Occupational Health and Safety leadership, the Senior Clinical Quality Analyst shapes quality improvement projects and evaluation frameworks that align with OSHA, HIPAA, JCAHO, and CMS regulatory standards across the organization. Partnering with clinical and non-clinical audiences to build strategic action plans and prepare for external audits, this role enables improved patient experience outcomes through rigorous quality management metrics and risk mitigation.

Primary Duties

• Demonstrate knowledge of applicable occupational health regulatory requirements including local, state, OSHA, HIPAA, CDC, JCAHO, and CMS standards.
• Design, create, and implement quality improvement projects and initiatives.
• Conduct and manage outcomes of various studies including analyzing, reviewing, forecasting, trending, and presenting information for quality management planning.
• Develop and present recommendations and alternatives for management and executive review.
• Assist in developing department strategic action plans.
• Develop and implement effective analysis, research, and evaluation of quality management metrics.
• Assist with preparedness for external audits and risk mitigation for potential OSHA complaints.
• Coordinate associated reporting and communications.

Skills & Qualifications

• Bachelor's Degree or equivalent work experience.
• Master's degree in nursing or public health preferred.
• Unrestricted and active RN license.
• Certified Occupational Health Nurse (COHN) or other certification in public health preferred.
• 2+ years of experience in occupational or public health.
• 2+ years of experience developing and implementing performance improvement projects or using data to develop intervention strategies to improve outcomes.
• Experience creating reports related to quality improvement and performance outcomes.
• Audit and compliance experience in a healthcare environment.
• Advanced proficiency in Microsoft Office applications including Outlook, Word, Excel, Visio, PowerPoint, and SharePoint.
• Ability to collect, analyze, and present data.
• Strong auditing skills.
• Strong communication and persuasion skills with both clinical and non-clinical audiences.

Sitting at the intersection of laboratory science and regulatory compliance, the Clinical Quality Analyst leads quality assurance and improvement activities within a clinical laboratory setting, supporting QC report review, CAP and CLIA inspection readiness, proficiency testing, and document management system oversight. Operating across internal quality teams, client reporting channels, and accrediting agency inspections, this role ensures that laboratory results meet the accuracy and compliance standards that providers and patients depend on.

Duties

• Provide monthly and quarterly quality metric reports for clients and senior leadership using databases and crystal reports.
• Update and maintain all lab general and quality procedures, forms, and associated documents using document management software.
• Review Quality Control reports for acceptability and report deficiencies as applicable.
• Provide data and reports for quality teams and support all Quality Improvement efforts.
• Schedule and conduct regular QA audits and inspections of assigned departments and facilities and perform audit reports.
• Ensure complete and accurate readiness for all inspections and maintain all necessary documents.
• Participate in regulatory and accrediting agency inspections when needed.
• Perform first-level review of proficiency testing results.
• Draft responses to regulatory complaints and inspections.
• Stay current with all regulatory agency and proficiency test requirements.
• Monitor the progress of implementation and subsequent use of the document management system.
• Participate in monthly Quality meetings and compose minutes.
• Serve as a resource on regulatory issues and compliance.

Education & Experience

• Bachelor's degree in Medical Technology or a Life Science.
• 1–2 years of previous experience as a Medical Technologist or Technician, or in a quality-related position in a clinical laboratory.
• General knowledge of laboratory regulations including CAP, CLIA, and ISO, as well as licensing requirements.
• Knowledge of CAP proficiency testing.
• Knowledge of audit-related requirements and procedures.
• Strong understanding of laboratory testing and Quality Control.
• Working knowledge of quality assurance and quality management best practices.
• Previous experience with an electronic data management system such as MasterControl is a plus.
• Proficient in MS Office programs.
• Excellent analytical, critical thinking, and problem-solving skills including Root Cause Analysis, CAPA, and autonomous problem solving.
• Strong written and verbal communication skills.
• High level of attention to detail with strong organizational skills.
• Ability to work independently and within a team environment.