Clinical Quality Review Nurse III

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🔥 1 minute ago

🌵 Arizona, Florida, +15 more states – Remote

🌵 Arizona – Remote 🐊 Florida – Remote 🌽 Illinois – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🐎 Kentucky – Remote 🌾 Nebraska – Remote 🌾 North Dakota – Remote 🌪️ Oklahoma – Remote 🚗 Michigan – Remote ❄️ Minnesota – Remote 🏰 Missouri – Remote 🗿 South Dakota – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⚔️ Virginia – Remote 🧀 Wisconsin – Remote

💵 $70.2k - $120.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

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Medica

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1975

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Medica is a nonprofit health plan and insurer with over 50 years of experience that provides individual & family plans, Medicare, Medicaid, and employer-provided health plans. It offers member services and tools for finding providers, managing benefits and claims, wellness programs, and community-focused initiatives through the Medica Foundation to advance health equity.

📋 Description

• Conduct medical record reviews and clinical quality audits across Medica’s network • Collect, review, and validate clinical documentation for compliance with quality standards • Identify documentation gaps and improvement opportunities using established criteria • Prepare audit findings supporting quality reporting and corrective action planning • Maintain accurate documentation of review activities • Perform data abstraction and documentation verification for required quality measures • Ensure accuracy and completeness of data submitted for accreditation and ratings programs • Collaborate with internal partners to clarify clinical requirements and documentation needs • Monitor trends and raise concerns affecting regulatory or accreditation outcomes • Complete audits related to CMS Cost, HEDIS, RADV, NCQA site visits, and other regulatory requirements • Review coded data and medical records for accuracy and compliance • Identify discrepancies and recommend corrective actions • Contribute data and insights to audit readiness and regulatory submissions • Provide feedback and guidance to providers on documentation expectations and audit results • Share clinical and coding insights with providers and internal teams • Support corrective action plans through education and follow-up • Recommend enhancements to review methods, tools, or workflows • Support process updates improving accuracy, consistency, or efficiency • Collaborate with colleagues to align practices with evolving regulatory and accreditation standards • Perform other duties as assigned

🎯 Requirements

• Associate’s or Bachelor's degree in Nursing • 5+ years of related work experience, including clinical quality chart reviews, data analysis, auditing and/or quality improvement experience • RN License required • Current coding certification: CCA, CPC, CPC-P, CPC-H, CCS, CCS-P, RHIT, or RHIA; or ability to obtain CPC or CRC coding certification within 1 year of employment or by Medica-determined timeframe • Experience and/or knowledge of HEDIS, NCQA, RADV, or other accreditation and quality measures strongly preferred • Knowledge of CPT and diagnosis codes strongly preferred • Ability to manage competing priorities and multiple deadlines • Demonstrated organizational and time management skills • Ability to make reliable independent decisions using analytical problem-solving skills • Strong attention to detail • Excellent written and verbal communication skills • Experience navigating electronic health records preferred • Proficiency with personal computers and software including Adobe Acrobat, Windows, Microsoft Office, Word, Excel, Outlook, Teams, SharePoint, OneNote, and OneDrive • Primary home address must be in a state where Medica is registered as an employer: Arkansas, Arizona, Florida, Georgia, Iowa, Illinois, Kansas, Kentucky, Michigan, Minnesota, Missouri, North Dakota, Nebraska, Oklahoma, South Dakota, Tennessee, Texas, Virginia, or Wisconsin • Must be legally authorized to work in the United States at the time of application • Medica does not offer work visa sponsorship for this role

🏖️ Benefits

• Competitive medical, dental, and vision benefits • PTO • Holidays • Paid volunteer time off • 401K contributions • Caregiver services • Other total rewards benefits