Registered Nurse (RN) Medicare Quality Assurance Reviewer

Clover Health

16h•$92,000 - $120,000•Remote

About The Position

The Utilization Management (UM) team plays a vital role in supporting Clover members throughout their care journey. The team is made up of experienced clinicians who combine clinical expertise with data-driven insights to support evidence-based decision-making. Working closely with providers and care partners, the UM team ensures that care transitions are smooth, efficient, and always focused on improving member outcomes while maintaining compliance with CMS guidelines. As a Registered Nurse (RN) Medicare Quality Assurance Reviewer, you will: Provide clinical expertise support for Clover vendors and Medical Directors. Create and assign inter-rater reliability reviews to RN reviewers and Medical Directors. Complete monthly MD Quality Assurance (QA) reviews to ensure clinical compliance with Medicare regulations. Service line clinical reviews. Clinical Medical Record Review Subject Matter Expert (SME). Identifying clinical opportunities for improvement and communicating to upper management. Tracking clinical performance and evaluation of vendors medical reviewers. Clinical support for new medical review process implementations. Monitor and track CMS Medicare clinical updates that impact Clover clinical processes, partner with management to implement clinical changes. Displays Flexibility to adjust work based on new challenges or feedback. Clinical collaboration with cross-functional departments. Success in this role looks like: By the end of your first 90 days: Build a strong foundation in Clover’s utilization management, quality assurance, and clinical review processes. Develop proficiency in Medicare regulations, clinical review requirements, and Clover’s quality standards. Establish effective working relationships with internal stakeholders, vendors, and Medical Directors. Consistently perform quality assurance reviews with accuracy, sound clinical judgment, and attention to compliance requirements. By 6 months: Independently manage quality assurance responsibilities across utilization management service lines. Serve as a reliable clinical resource for quality, compliance, and review-related questions. Contribute to process improvements by identifying opportunities to enhance quality, consistency, and operational effectiveness. Partner effectively with vendors, Medical Directors, and cross-functional teams to support quality outcomes and regulatory compliance. Future state: Be recognized as a trusted clinical quality and utilization management subject matter expert. Drive continuous improvement through trend analysis, performance insights, and recommendations that strengthen quality and compliance programs. Support the evolution of clinical review processes, technology-enabled solutions, and operational initiatives that improve efficiency and member outcomes. Influence organizational success by maintaining high standards of clinical excellence, regulatory compliance, and collaborative partnership across the organization.

Requirements

Active and valid RN license; required.
Minimum of 3 years of Medicare Utilization Management medical necessity review experience; required.
Strong knowledge of applying CMS guidelines, and NCD-LCD to Medicare medical necessity reviews; required.
Quality Assurance experience; required.
Excellent interpersonal skills and ability to communicate with patients and colleagues.

Nice To Haves

Experience working in a Medicare Advantage plan; preferred
RN clinical experience in a hospital setting; preferred.
Previous experience in leading vendor relationships and building clinical review teams.
Experience working remotely; preferred.

Responsibilities

Provide clinical expertise support for Clover vendors and Medical Directors.
Create and assign inter-rater reliability reviews to RN reviewers and Medical Directors.
Complete monthly MD Quality Assurance (QA) reviews to ensure clinical compliance with Medicare regulations.
Service line clinical reviews.
Clinical Medical Record Review Subject Matter Expert (SME).
Identifying clinical opportunities for improvement and communicating to upper management.
Tracking clinical performance and evaluation of vendors medical reviewers.
Clinical support for new medical review process implementations.
Monitor and track CMS Medicare clinical updates that impact Clover clinical processes, partner with management to implement clinical changes.
Displays Flexibility to adjust work based on new challenges or feedback.
Clinical collaboration with cross-functional departments.