Nurse Quality Analyst (RN)

Acentra Health, LLC•UNAVAILABLE, UNAVAILABLE

1d•Remote

About The Position

Acentra Health is seeking a Nurse Quality Analyst to support the Integrated Health Solutions division by evaluating the quality, accuracy, consistency, and timeliness of utilization management reviews across Medicaid programs. The role conducts structured audits of clinical reviews, including AI-assisted reviews; validates alignment with clinical criteria and contract requirements; identifies trends and improvement opportunities; and works with operational and clinical leaders to strengthen review quality. The analyst also supports quality initiatives and helps educate clinical staff on quality processes, audit standards, documentation expectations, and continuous improvement practices. This position is fully remote within the United States. Candidates in the Eastern Time Zone are preferred; scheduling flexibility is available for Central and Mountain Time Zone candidates. The role may also support medical record abstraction, clinical case reviews, quality studies, and other assigned clinical or quality activities, and serve as backup to the Director of Operations as needed.

Requirements

Active, unrestricted Registered Nurse (RN) license.
Completion of a state-approved nursing education program resulting in a certificate, diploma, or associate degree, in accordance with applicable state licensure requirements; a bachelor's degree is preferred.
At least 3 years of clinical nursing, utilization management, quality, or related healthcare experience, with demonstrated experience performing or overseeing quality audits.
Extensive experience with Medicaid programs.
Experience reviewing prior authorization, concurrent review, retrospective review, medical necessity, or other utilization management cases using established clinical criteria.
Strong analytical, critical thinking, and clinical judgment skills.
Ability to interpret and apply Medicaid policies, contract requirements, clinical criteria, and quality standards.
Strong written, verbal, facilitation, presentation, and training skills.
Ability to provide objective, respectful, actionable feedback to clinical staff and leaders.
Ability to identify trends, conduct root-cause analysis, and support sustainable process improvement.
Ability to work independently, manage competing priorities, meet deadlines, and maintain confidentiality.
Proficiency in Microsoft Office and comfort learning quality reporting, audit, utilization management, and workflow technology platforms.

Nice To Haves

Bachelor's degree in nursing is preferred.
Experience evaluating clinical documentation, reviewer determinations, audit results, and compliance with state or health plan requirements.
Experience with quality improvement methods, audit tools, performance measurement, inter-rater reliability, or clinical staff education.
Experience with AI-assisted clinical review, clinical decision support, automation, or technology-enabled utilization management workflows.

Responsibilities

Plan, develop, implement, and monitor internal quality assurance and improvement programs for consistent, efficient, compliant, and member-centered utilization management operations.
Conduct prospective, concurrent, retrospective, and focused quality audits of Medicaid utilization management reviews, including reviews supported by AI or other automation tools.
Evaluate clinical review accuracy, completeness, consistency, timeliness, medical necessity rationale, use of clinical criteria, and compliance with state, federal, and contractual requirements.
Validate AI-assisted recommendations and automated outputs against clinical documentation, applicable criteria, and policies.
Develop and apply standardized audit tools and quality methods to assess reviewer performance, accuracy, inter-rater reliability, and other quality measures in collaboration with Operations Management and Medical Directors.
Document and analyze audit findings, identify trends and root causes, provide constructive feedback, and communicate concerns and recommendations to clinical staff and operational leadership.
Maintain internal quality control databases, audit records, trend reports, action plans, and other documentation; adjust data collection and reporting processes as needed to meet contractual requirements.
Prepare recurring and ad hoc quality reports for leadership and internal stakeholders, escalating significant risks, patterns, and compliance concerns as appropriate.
Collaborate with operations managers, clinical leaders, medical directors, training teams, and subject matter experts to identify improvement opportunities, implement corrective actions, and monitor effectiveness.
Identify training needs and coordinate, develop, and deliver education for clinical and DHA staff on onboarding, refresher training, medical record abstraction, clinical reviews, audit standards, quality measures, clinical criteria, and inter-rater reliability.
Facilitate calibration sessions and targeted coaching to improve clinical review consistency, documentation accuracy, and quality performance.
Support departmental workload through medical record abstraction, clinical case reviews, quality studies, and other assigned clinical or quality activities.
Stay current with Medicaid utilization management practices, regulatory and contractual requirements, quality standards, and responsible use of AI in clinical workflows.
Serve as backup to the Director of Operations as needed.
Read, understand, and comply with corporate policies, including HIPAA Privacy and Security Rules.