Clinical Quality Nurse Reviewer, Sr. Specialist
About The Position
We are seeking a talented individual for a Clinical Quality Nurse Reviewer, Sr. Specialist who is responsible for performing on-going quality assurance audits of the work performed by clinical staff. This person is responsible for complex quality reviews to determine if decision by review staff matches medical records and approved review methodologies. Responsibilities include reviewing documentation to ensure all aspects of the review audit have been addressed properly and accurately. Performing inter-rater reliability assessments and quality assurance auditors for multiple review types including Place of Service, Level of Care, Readmissions, Utilization Management and other specialty reviews.
Requirements
- Active, unrestricted RN license in the U.S. and in the candidate's state of primary residence, with a current multistate compact (NLC) license required.
- Associate degree required; bachelor's degree preferred.
- 5+ years clinical experience in acute setting
- 3+ years medical record review/auditing experience preferred
- Expert level experience applying MCG and/or InterQual criteria
- Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of determinations.
- Ability to analyze and evaluate medical information and to apply clinical review guidelines or judgement to make clinical determinations.
- Ability to multi-task in a fast-paced production environment.
Responsibilities
- Perform QA checks on complex clinical claim reviews
- Review and analyze claim data and medical records using approved guidelines
- Document determinations clearly and concisely
- Report quality findings for trending and performance insights
- Identify trends and support remediation through training or educational materials
- Ensure documentation accuracy while meeting quality and production goals
- Assist with onboarding and mentoring new reviewers
- Maintain current knowledge of clinical criteria and required CEUs
- Attend trainings and meetings to stay aligned with policies and regulations
- Cross-train on multiple claim types to support workload flexibility
- Serve as SME for proposals and department initiatives
- Support projects, reporting, and data analysis as needed
- Consistently meet productivity and quality targets
- Apply clinical judgement to evaluate medical information and review outcomes
Benefits
- You'll have the opportunity to grow your career in a company that values work flexibility, learning, and career development.
- All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance.
- We also have a variety of leadership and technical development academies to help build your skills and capabilities.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
Number of Employees
5,001-10,000 employees
