Utilization Management QA Analyst

Job Description: Utilization Management (UM) Quality Assurance Nurse

Job Summary

The Utilization Management (UM) Quality Assurance Nurse is responsible for supporting quality improvement initiatives by conducting comprehensive audits, analyzing operational processes, identifying trends and opportunities for improvement, and ensuring compliance with utilization management policies and procedures. This role plays a critical part in maintaining the accuracy, consistency, and quality of UM reviews, documentation, and member interactions while supporting operational excellence and regulatory compliance.

The QA Nurse collaborates with leadership and operations teams to evaluate performance, provide actionable insights, develop educational materials, support system implementations, and contribute to continuous process improvement initiatives.

Key Responsibilities

Quality Assurance & Auditing

• Perform quality assurance audits on completed prospective, concurrent, and retrospective utilization management clinical reviews involving inpatient, outpatient, ambulatory, and ancillary services.
• Evaluate accuracy, completeness, timeliness, and compliance of UM documentation and decision-making processes.
• Conduct clinical quality and operational audits to ensure adherence to policies, procedures, benefit plans, regulatory requirements, and customer service standards.
• Evaluate UM clinical decision-making against MCG, CMS, regulatory, policy, and contractual requirements.
• Identify, document, and communicate audit findings, root cause, trends, risks, and opportunities for process improvement.
• Analyze audit results and trends to identify recurring issues, potential root causes, and opportunities for corrective or performance improvement activities
• Maintain and support the development of UM audit tools, methodologies, scoring standards, and related quality documentation
• Support regulatory compliance through quality audit, data analysis, documentation review, and identification of potential compliance risks.

Analysis & Reporting

• Assist in monitoring quality initiatives, outcomes, metrics, and objectives to ensure performance goals are achieved.
• Prepare reports, presentations, and other materials as needed to communicate audit results and recommendations to management.
• Support root cause analysis activities and recommend corrective and preventive actions.

Education & Training

• Support UM leadership in providing targeted education, audit feedback, and clinical coaching to UM staff based on identified quality findings and trends
• Provides recommendation related to, but not limited to, the following:
  • Utilization Management policies and procedures
  • Clinical documentation standards
  • Regulatory and compliance requirements
  • Quality improvement initiatives
• Assist in the creation of user guides, training manuals, and process documentation.

Process Improvement & Project Support

• Collaborate with leadership to identify operational challenges and recommend innovative solutions.
• Support change management initiatives by assisting with planning, organizing, and controlling project activities.
• Participate in User Acceptance Testing (UAT), system enhancements, and implementation projects as needed.
• Assist in developing business requirements documentation and workflow improvement recommendations.
• Support process redesign efforts to improve efficiency, accuracy, and quality outcomes.

Collaboration & Stakeholder Support

• Partner with operations teams to validate audit results and quality findings.
• Maintain effective communication with internal stakeholders and leadership regarding quality trends and performance improvement opportunities.
• Maintain comprehensive knowledge of business operations, products, programs, organizational structure, and utilization management processes.

Additional Responsibilities

• Perform other duties and special projects as assigned.
• Support departmental and organizational objectives through ongoing quality improvement efforts.

Required Qualifications

Education

• Bachelor’s degree in Nursing.
• Advanced degrees such as Master of Arts in Nursing (MAN) or Master of Science in Nursing (MSN), preferred but not required.
• Equivalent combination of education and experience may be considered.

Experience

• Minimum of 5+ years in health-related field required, including at least 3 years of experience in utilization management, clinical quality, quality assurance, appeals and grievances, or a related clinical quality function.

Preferred Experience

• Experience with clinical quality auditing, audit methodology, root cause analysis, and trend analysis.
• Experience with regulatory or accreditation readiness.
• Experience in managed care, health plans, or third-party administration environments.
• Experience supporting process improvement or operational quality initiatives.

Preferred Systems Knowledge

• HealthEdge HRP
• GuidingCare
• JIRA
• Other utilization management platforms and workflow systems

Required Skills, Knowledge, and Abilities (SKA)

• US RN License
• Strong analytical and problem-solving capabilities.
• Excellent verbal and written communication skills with the ability to communicate complex concepts clearly.
• Strong organizational and planning skills with the ability to manage multiple priorities.
• High attention to detail and commitment to accuracy.
• Advanced proficiency in Microsoft Office applications, including:
  • Excel
  • Word
  • PowerPoint
  • Outlook
• Ability to independently evaluate data and identify trends, gaps, and opportunities for improvement.
• Ability to work both independently and collaboratively in a team environment.
• Strong interpersonal skills and ability to interact effectively with employees, leaders, and clients at all organizational levels.
• Flexibility and adaptability in a fast-paced and changing environment.
• Ability to create and maintain business requirements documents, training materials, and procedural guides.
• Understanding of quality assurance methodologies, audit principles, and continuous improvement practices.
• Knowledge of utilization management workflows, healthcare benefits, and regulatory requirements.

Appian, CPT, Claims Management, Clinical Documentation Improvement, Compliance Management, Functional Testing, HIPAA, Healthcare Systems, ICD-10-CM, ICD-9, MCG