Supervisor, Clinical Quality Review

🔥 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

💵 $78.7k - $118k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

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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

• leads day-to-day clinical review and medical record operations supporting complex, time-sensitive regulatory audits and quality initiatives • provides direct supervision, coaching, and workload management for Clinical Quality Review RNs • ensures audit deliverables, documentation standards, and regulatory timelines are met • exercises independent judgment, proactively identifies operational risks, resolves escalations, and adapts workflows in response to changing audit requirements, data availability, and business priorities • assists Manager with supporting an efficient department operation and workflow • works with other departments to assure workflow is adequate to meet the needs of the project/audit • coaches staff through complex, ambiguous, or high-risk audit scenarios • identifies and assists in resolution of escalated and/or complex issues • supports daily operations and long-range planning for the department • collaborates with department and all business segments to ensure that consistent, effective and timely communication occurs • assists with data collection and audits • develops and/or assist with training and training materials • works with HR to recruit and hire new staff • supports staff resilience and performance during peak audit periods • balances productivity expectations with quality and compliance standards

🎯 Requirements

• Bachelor's degree or equivalent experience in a related field (Nursing preferred) • 5 years of relevant clinical healthcare experience beyond degree, including broad-based clinical practice or equivalent clinical review experience • Active Registered Nurse (RN) License preferred • 2 years of prior Lead, Supervisor, or Clinical Leadership experience • 4 years of broad-based nursing or clinical experience, or an equivalent depth of experience within a clinically focused healthcare discipline • 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities • Demonstrated experience managing clinical review, quality, or audit work under strict regulatory timelines • Demonstrated experience and knowledge of regulatory medical record documentation requirements, including: HEDIS and STARS Off‑Season Data Collection, CMS Cost Audits, RADV and Clinical Data Validation • Knowledge of ICD‑10 and CPT coding

🏖️ Benefits

• competitive medical, dental, vision • PTO • Holidays • paid volunteer time off • 401K contributions • caregiver services