USRN Quality Analyst

Job Description:

Education & Licensure
• Nursing Degree
• Active, unrestricted US Registered Nurse (RN) License
• Multi-state Compact RN License preferred
• License must remain active and in good standing throughout employment

Experience
Required: • Minimum 3 years of clinical nursing experience
• Minimum 2 years of experience in Specialty Pharmacy, Utilization Management, Care Management, Disease Management, or related clinical program
• Minimum 1 year of experience in Quality Assurance, Clinical Auditing, Compliance Review, or Clinical Quality Monitoring
• Experience reviewing clinical documentation, patient interactions, and quality outcomes

Preferred: • Specialty Pharmacy experience
• Telephonic Clinical Nurse experience
• Experience supporting medication adherence and patient engagement programs
• Experience conducting calibration sessions with operations and client stakeholders
• Knowledge of URAC, NCQA, CMS, and specialty pharmacy quality standards

Mandatory Skills
• Strong clinical judgment and critical thinking skills
• Ability to assess appropriateness of clinical interventions, patient education, and adherence support activities
• Ability to evaluate completeness and accuracy of clinical documentation and case records
• Knowledge of healthcare regulations, including HIPAA requirements
• Strong analytical, reporting, and trend-analysis skills
• Excellent written and verbal communication skills
• Ability to provide objective feedback supported by clinical rationale
• Strong organizational and time-management skills

Roles & Responsibilities
• Conduct quality audits of clinical interactions, patient outreach activities, and clinical documentation in accordance with client requirements, specialty pharmacy standards, and regulatory expectations
• Evaluate the quality and accuracy of patient education, medication adherence discussions, therapy support activities, and clinical documentation
• Assess compliance with clinical workflows, policies, procedures, and regulatory requirements
• Identify quality trends, documentation gaps, compliance risks, and opportunities for process improvement
• Document audit findings and maintain accurate records within designated quality systems
• Conduct calibration sessions with Operations, Training, Clinical Leadership, and Client stakeholders to ensure consistent interpretation of quality standards
• Partner with Operations and Training to identify root causes and implement corrective actions based on audit results and quality trends
• Develop and deliver quality reports, scorecards, and performance insights to leadership and client stakeholders
• Support quality improvement initiatives focused on member experience, clinical excellence, regulatory compliance, and operational effectiveness
• Escalate compliance risks, patient safety concerns, and critical quality findings as appropriate
• Maintain compliance with HIPAA and all applicable federal, state, client, and organizational requirements