Clinical Quality Evaluator- Core (PHL)

Position Title

Clinical Quality Evaluator- Core (PHL)

Primary Responsibilities

• Evaluate the quality and accuracy of transactions and/or communications with providers, groups, and/or policyholders.
• Identify, document, and report any transaction errors or communication issues in a timely manner to ensure prompt resolution.
• Track and trend audit results, providing feedback to management.
• Conduct calibration sessions to evaluate and ensure all teams are aligned with QA guidelines.
• Identify and report systemic issues that create ongoing quality concerns.
• Conduct root cause analysis using RCA tools to determine underlying causes of quality opportunities.
• Recommend, implement, and monitor preventive and corrective actions to ensure quality standards are achieved.
• Generate monthly reports of audit findings and support clients with identified issues.
• Develop additional reports as requeste...