Clinical Quality Review Nurse III

This is a fully remote position, open to applicants in Arizona, +16 more states.

📋 Description

• Conduct reviews of medical records and clinical quality audits throughout Medica’s network.

• Gather, assess, and verify clinical documentation to ensure compliance with quality standards.

• Detect gaps in documentation and identify opportunities for improvement based on established criteria.

• Compile audit findings that support quality reporting and the planning of corrective actions.

• Maintain precise records of review activities.

• Execute data abstraction and verify documentation for necessary quality measures.

• Ensure the accuracy and completeness of data submitted for accreditation and rating programs.

• Collaborate with internal partners to clarify clinical requirements and documentation needs.

• Monitor trends and address concerns that may impact regulatory or accreditation outcomes.

• Conduct audits related to CMS Cost, HEDIS, RADV, NCQA site visits, and other regulatory requirements.

• Assess coded data and medical records for accuracy and compliance.

• Identify discrepancies and suggest corrective measures.

• Contribute data and insights to ensure audit readiness and support regulatory submissions.

• Provide feedback and guidance to providers on documentation expectations and audit outcomes.

• Share clinical and coding insights with healthcare providers and internal teams.

• Assist in implementing corrective action plans through education and follow-up.

• Recommend improvements to review methods, tools, or workflows.

• Support process enhancements that increase accuracy, consistency, or efficiency.

• Work collaboratively with colleagues to ensure practices align with evolving regulatory and accreditation standards.

• Perform additional duties as assigned.

⛳️ Requirements

• Associate’s or Bachelor's degree in Nursing.

• 5+ years of relevant work experience, including clinical quality chart reviews, data analysis, auditing, and/or quality improvement.

• RN License is mandatory.

• Current coding certification: CCA, CPC, CPC-P, CPC-H, CCS, CCS-P, RHIT, or RHIA; or the ability to obtain CPC or CRC coding certification within one year of employment or within a Medica-determined timeframe.

• Experience and/or familiarity with HEDIS, NCQA, RADV, or other accreditation and quality measures is strongly preferred.

• Knowledge of CPT and diagnosis codes is strongly preferred.

• Capacity to manage competing priorities and adhere to multiple deadlines.

• Proven organizational and time management skills.

• Ability to make independent decisions based on analytical problem-solving skills.

• Strong attention to detail.

• Excellent written and verbal communication abilities.

• Experience with electronic health records is 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 provide work visa sponsorship for this position.

🏝️ Benefits

• Competitive medical, dental, and vision benefits.

• Paid Time Off (PTO).

• Holiday pay.

• Paid volunteer time off.

• 401K contributions.

• Caregiver services.

• Additional total rewards benefits.