Registered Nurse – Training and Quality Control Coordinator
About The Position
Broadway Ventures is seeking a qualified Registered Nurse – Training and Quality Control Coordinator to support medical review operations for Palmetto GBA. This role is responsible for reviewing medical review decisions for accuracy, ensuring proper application of CMS guidelines, supporting quality control initiatives, training clinical staff, and assisting with provider inquiries and appeals-related medical coverage issues. The ideal candidate will have strong clinical judgment, experience applying CMS instructions and medical review procedures, and the ability to provide education, feedback, and quality assurance support to medical review teams.
Requirements
- Active and unrestricted Registered Nurse license.
- Strong knowledge of CMS guidelines, medical review procedures, and healthcare coverage requirements.
- Experience reviewing medical documentation and applying clinical judgment to coverage or medical necessity decisions.
- Ability to evaluate clinical staff performance and provide constructive feedback.
- Experience developing or supporting quality control, quality assurance, or audit programs.
- Strong written and verbal communication skills.
- Ability to create reports, reference materials, training guides, and educational content.
- Strong organizational skills and attention to detail.
- Ability to work independently and collaborate with management, clinical staff, provider service teams, and audit departments.
Nice To Haves
- Prior experience with Medicare, Medicaid, CMS contractors, or healthcare claims review.
- Experience responding to provider inquiries, appeals, or coverage-related requests.
- Background in medical review, utilization review, quality assurance, auditing, or clinical education.
- Experience training clinical staff or developing continuing education workshops.
- Familiarity with provider billing practices and program integrity concepts.
Responsibilities
- Review medical review decisions for accuracy and ensure CMS instructions and guidelines are applied correctly.
- Develop, implement, and support a quality control program designed to evaluate clinical staff’s technical knowledge and medical judgment.
- Provide feedback to management and staff regarding quality review findings.
- Deliver remedial training when necessary to address identified performance or knowledge gaps.
- Assist provider service departments with medical coverage issues to ensure consistent application of CMS guidelines.
- Respond to specific provider inquiries and appeals requests related to medical coverage and review decisions.
- Develop and maintain departmental reference manuals used to support proper application of CMS instructions.
- Provide continuing education workshops for medical reviewers on coverage issues, CMS updates, and medical advances.
- Train new staff on CMS guidelines, medical review procedures, and internal review processes.
- Prepare monthly reports for management outlining quality control results, adjustment data, and reopening results summaries.
- Provide input to the medical review audit department regarding actions taken in response to provider billing practices to help identify and target potential program abuse.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
