Clinical Quality Review Nurse III

Medica•,

10d•$70,200 - $105,315•Remote

About The Position

The Clinical Quality Review Nurse III supports quality performance by conducting medical record reviews, data collection, and clinical audits across Medica’s network. The role evaluates documentation accuracy, adherence to clinical standards, and compliance with regulatory and accreditation requirements, including HEDIS, STARS, CMS Cost Audit, and RADV. It applies advanced nursing and coding expertise to identify improvement opportunities and ensure reliable quality outcomes. The position also serves as a resource to others by sharing clinical and coding knowledge that strengthens quality review processes. RN licensure and coding certification are required, subject to the stated option to obtain a qualifying certification within one year of employment or another Medica-determined timeframe. Other duties may be assigned. This is a remote position. Candidates must have a primary home address in a state where Medica is registered as an employer: AR, AZ, FL, GA, IA, IL, KS, KY, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, or WI. Medica does not offer work visa sponsorship; candidates must be legally authorized to work in the United States at the time of application, and employment is contingent on verification of identity and work eligibility. The full salary grade is $70,200–$120,400, with a typical hiring range of $70,200–$105,315. Placement depends on factors including education, work experience, certifications or licensure, scope and responsibility, internal pay equity, and external market data. Medica offers a total rewards package that includes medical, dental, and vision coverage, PTO, holidays, paid volunteer time off, 401(k) contributions, caregiver services, and other benefits. Compensation and benefits are subject to change, subject to applicable law.

Requirements

Associate’s or bachelor’s degree in Nursing.
At least 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; alternatively, ability to obtain CPC or CRC certification within one year of employment or within a timeframe determined by Medica.
Candidates must be legally authorized to work in the United States at the time of application; employment is contingent on verification of identity and work eligibility.
For this remote role, candidates must have a primary home address in a state where Medica is registered as an employer: AR, AZ, FL, GA, IA, IL, KS, KY, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, or WI.

Nice To Haves

Experience and/or knowledge of HEDIS, NCQA, RADV, or other accreditation and quality measures.
Knowledge of CPT and diagnosis codes.
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.
Proficiency with personal computers and supporting software, including Adobe Acrobat, Windows, and Microsoft Office products such as Word, Excel, Outlook, Teams, SharePoint, OneNote, and OneDrive.

Responsibilities

Collect, review, and validate clinical documentation for compliance with quality standards.
Identify documentation gaps and improvement opportunities using established criteria.
Prepare audit findings to support quality reporting and corrective action planning.
Maintain accurate and organized 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 that may affect regulatory or accreditation outcomes.
Review coded data and medical records to verify accuracy and compliance with program rules, including CMS Cost, HEDIS, RADV, NCQA site visits, and other regulatory requirements.
Identify discrepancies and recommend corrective actions when documentation does not meet standards.
Contribute data and insights to support audit readiness and regulatory submissions.
Apply RN and coding expertise to support high-quality, compliant documentation practices.
Provide providers with feedback and guidance on documentation expectations and audit results.
Share clinical and coding insights to improve documentation accuracy and quality outcomes.
Help internal teams understand program requirements and quality measure criteria.
Support corrective action plans through targeted education and follow-up.
Recommend improvements to review methods, tools, or workflows based on audit findings.
Support process updates that improve accuracy, consistency, or efficiency.
Share observations from clinical reviews to inform broader quality initiatives.
Collaborate with colleagues to align practices with evolving regulatory and accreditation standards.
Perform other duties as assigned.