Registered Nurse, Medicare Quality Assurance Reviewer

Job not on LinkedIn

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $92k - $120k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔧 QA Engineer (Quality Assurance)

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

Apply Now

Find Similar Remote Jobs

Receive Emails For Remote Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

Clover Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Clover Health (Nasdaq: CLOV) is a physician enablement company focused on seniors who have historically lacked access to affordable, high-quality healthcareWe aim to provide great care, in a sustainable way, by having a business model built around improving medical outcomes while lowering avoidable costs. We do this while taking a holistic approach to understanding the health needs and social risk factors of those under our care. This strategy is underpinned by our proprietary software platform, the Clover Assistant, which is designed to aggregate patient data from across the health ecosystem to support clinical decision-making by presenting physicians and other providers with real-time, personalized recommendations at the point of care.Making care more accessible is at the heart of our business, and we believe patients should have the freedom to choose their doctors. We offer affordable Medicare Advantage plans with extensive benefits, provide primary care physicians with the Clover Assistant, and also make comprehensive home-based care available via the Clover Home Care program.With our corporate headquarters in Nashville, Clover’s workforce is distributed around the U.S. and also includes a team of world-class technologists based in Hong Kong. We manage care for Medicare Advantage members in Alabama, Arizona, Georgia, Mississippi, New Jersey, Pennsylvania, South Carolina, Tennessee, and Texas.We are hiring software engineers, data scientists, designers and product folks who can help us understand our members’ wellness and steer them clear of any health risks down the road.If you’re a passionate person and interested in changing healthcare for the better, then Clover Health may just be the place for you.

📋 Description

• Provide clinical expertise support for Clover vendors and Medical Directors. • Create and assign inter-rater reliability reviews to RN reviewers and Medical Directors. • Complete monthly MD Quality Assurance (QA) reviews to ensure clinical compliance with Medicare regulations. • Service line clinical reviews. • Clinical Medical Record Review Subject Matter Expert (SME). • Identifying clinical opportunities for improvement and communicating to upper management. • Tracking clinical performance and evaluation of vendors medical reviewers. • Clinical support for new medical review process implementations. • Monitor and track CMS Medicare clinical updates that impact Clover clinical processes, partner with management to implement clinical changes. • Displays Flexibility to adjust work based on new challenges or feedback. • Clinical collaboration with cross-functional departments.

🎯 Requirements

• You have an active and valid RN license; required. • You have a minimum of 3 years of Medicare Utilization Management medical necessity review experience; required. • You have a strong knowledge of applying CMS guidelines, and NCD-LCD to Medicare medical necessity reviews; required. • You have experience working in a Medicare Advantage plan; preferred. • You have Quality Assurance experience; required. • You have RN clinical experience in a hospital setting; preferred. • You have previous experience in leading vendor relationships and building clinical review teams. • You have excellent interpersonal skills and ability to communicate with patients and colleagues. • You have experience working remotely; preferred.

🏖️ Benefits

• Financial Well-Being: Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities. Additionally, we offer a performance-based bonus program, 401k matching, and regular compensation reviews to recognize and reward exceptional contributions. • Physical Well-Being: We prioritize the health and well-being of our employees and their families by providing comprehensive medical, dental, and vision coverage. Your health matters to us, and we invest in ensuring you have access to quality healthcare. • Mental Well-Being: We understand the importance of mental health in fostering productivity and maintaining work-life balance. To support this, we offer initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy. Additionally, we embrace a remote-first culture that supports collaboration and flexibility, allowing our team members to thrive from any location. • Professional Development: Developing internal talent is a priority for Clover. We offer learning programs, mentorship, professional development funding, and regular performance feedback and reviews. • Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities • Reimbursement for office setup expenses • Monthly cell phone & internet stipend • Remote-first culture, enabling collaboration with global teams • Paid parental leave for all new parents • And much more!