Clinical Quality Study Analyst

Serving the Community Health Care Needs of our Nation’s Veterans It's Who We Are. It's What We Do. TriWest Healthcare Alliance serves our nation’s Veterans as the partner to the Department of Veterans Affairs (VA) in administering the Veterans Choice Program (VCP) and Patient-Centered Community Care (PC3) Program. We are committed to providing Veterans with the community health care they earned and deserve! TriWest’s dedicated staff—with both military and business experience—brings together the best of the military and business worlds to ensure optimal organizational excellence and superior service to serve America’s Veterans. The health care providers in our network and our business partners strive to continually support the community health care needs of our nation’s Veterans by providing exceptional customer service. Since our founding in 1996, TriWest Healthcare Alliance has been On a Mission to Serve® our nation’s Veterans and military community by delivering award-winning customer service and providing access to high-quality health care through our quality network of providers.

Profile: We offer remote work opportunities (AK, AR, AZ, CO, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, WA, WI & WY only). Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position. Veterans, Reservists, Guardsmen and military family members are encouraged to apply! Job Summary: Conducts focused reviews, quality studies, and quality improvement projects according to appropriate contract standards. Investigates medical records retrospectively for potential quality and utilization issues. Ensures compliance with the program requirements for Clinical Quality Management (CQM) for Veterans and/or DoD beneficiaries. Maintains URAC standards in work products.

Conducts research and writes clinical quality studies to identify, develop and evaluate processes to improve delivery of care to Veterans and/or DoD beneficiaries. Acts as facilitator on quality improvement team projects and utilizes appropriate quality improvement methodologies and standardized quality management tools. Leads and performs quality management audits. Identifies, develops, and monitors focused reviews and other quality studies. Identifies Potential Quality Issues (PQIs) by performing a timely review of the medical records. This includes researching, investigating, analyzing, and preparing case summaries with recommendations for further review. Reviews Potential Quality Issues with Medical Directors when appropriate. Prepares peer reviewed cases for quality committees and monitors corrective action plans. Uses data management software to identify physician practice patterns, over- and under-utilization of care and services, complication rates, and high-cost outliers. Prepares and submits activity and projects reports. Performs other duties as assigned. Regular and reliable attendance is required.