Quality of Care, Clinical Review Nurse

This is a fully remote position, open to applicants in Tennessee.

📋 Description

• Perform timely and efficient reviews and investigations of potential quality of care concerns.

• Engage in quality improvement and management initiatives in line with state and federal regulatory standards.

• Analyze medical records to ensure appropriateness of care.

• Evaluate the clinical performance of physicians and other healthcare professionals.

• Ensure the confidentiality of sensitive documents, records, discussions, and information.

• Keep the Quality of Care Manager informed about activities, recognized issues, and measures taken to address them.

• Identify trends, propose recommendations, and present actionable solutions to enhance quality outcomes and the member experience.

• Communicate findings related to quality, clinical, operational, or regulatory matters to leadership, providers, committees, and cross-functional stakeholders.

⛳️ Requirements

• Must be a Registered Nurse (RN) with an unrestricted license in the state of operation.

• A minimum of 5 years of comprehensive knowledge of healthcare processes.

• Familiarity with managed care processes.

• Strong organizational abilities to meet deadlines and manage multiple priorities.

• Proficient verbal and written communication skills.

• Computer proficiency, including Microsoft Word, Access, and Excel.

• In-depth understanding of common patient disease processes and standard treatment methods.

• Extensive knowledge of medical terminology and commonly utilized equipment.

• Capability to assess medical records for appropriateness of care.

• Ability to evaluate and judge the clinical performance of physicians and other healthcare professionals.

• Strong analytical, assessment, and problem-solving abilities.

• Effective communication skills for conveying complex information and documenting according to standards.

• Intermediate skills in Word, PowerPoint, Excel, and Outlook; basic competency in data entry and database navigation.

• Ability to maintain confidentiality regarding sensitive information.

• Self-motivated and capable of working independently.

• Exceptional attention to detail and accuracy in work.

• Preferred: skills in presentation and facilitation.

• Preferred: experience in conducting clinical reviews, quality of care investigations, root cause analysis, and issue resolution.

• Preferred: experience in developing and delivering training or presentations.

• Preferred: experience in interpreting and communicating complex clinical information and findings.

• Preferred: familiarity with Quality of Care, Quality Management, Quality Improvement, Patient Safety, Risk Management, Appeals, Grievances, or related initiatives.

• Preferred: knowledge of CMS, NCQA, Medicare, Medicaid, and related regulatory requirements.

• Sponsorship is not available.

🏝️ Benefits

• Tailored development plans and opportunities for professional growth.

• Comprehensive health and wellness benefits.

• 401(k) savings plan.

• Pension plan.

• Paid time off.

• Paid parental leave.

• Disability insurance.

• Supplemental life insurance.

• Employee assistance program.

• Paid holidays.

• Tuition reimbursement.

• Annual incentive bonus plan.

• Additional incentives.