Supervisor, Clinical Quality Review

Medica•Minnetonka, MN

1d•Hybrid

About The Position

Medica is a nonprofit health plan with over a million members, serving communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. The organization is dedicated to delivering personalized health care experiences and collaborating closely with providers to ensure members receive genuine care. Medica operates as a team that values accountability, data-driven decisions, continuous learning, and collaboration. Its mission is to support members and employees in critical moments, fostering a community of connected care where coordinated, quality service is standard and every member feels valued. The Supervisor, Quality Reviewers is responsible for leading the day-to-day clinical review and medical record operations that support complex, time-sensitive regulatory audits and quality initiatives. This role involves direct supervision, coaching, and workload management for Clinical Quality Review RNs, ensuring that audit deliverables, documentation standards, and regulatory timelines are consistently met. The Supervisor is expected to exercise independent judgment, proactively identify operational risks, resolve escalations, and adapt workflows in response to evolving audit requirements, data availability, and business priorities. Successful candidates are described as organized, adaptable leaders who are comfortable making decisions with incomplete information, managing competing priorities, and providing support to staff through complex regulatory work.

Requirements

Bachelor's degree or equivalent experience in a related field
5 years of relevant clinical healthcare experience beyond degree, including broad-based clinical practice or equivalent clinical review experience
Candidates without an RN license must possess relevant clinical licensure or credentials appropriate to their healthcare discipline and demonstrate equivalent clinical competency
Minimum 2 years of prior Lead, Supervisor, or Clinical Leadership experience
4 years of broad-based nursing or clinical experience, or an equivalent depth of experience within a clinically focused healthcare discipline
Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
Demonstrated experience managing clinical review, quality, or audit work under strict regulatory timelines
Demonstrated experience and knowledge of regulatory medical record documentation requirements, including: HEDIS and STARS Off-Season Data Collection, CMS Cost Audits, RADV and Clinical Data Validation
Knowledge of ICD-10 and CPT coding
Experience leading teams through frequent change and evolving requirements
Ability to make independent operational decisions in fast-paced, highly regulated environments
Demonstrated ability to balance quality, compliance, and productivity expectations
Demonstrated effective project management skills, including: Use of planning and tracking tools, Development of achievable goals, timelines, and deliverables, Innovative and efficient use of resources
Advanced computer skills, including Adobe Acrobat and Microsoft 365 applications (Word, Outlook, PowerPoint, Excel, Teams, SharePoint)
3–5 years of experience communicating effectively with staff and leaders
Proven team-building, coaching, and mentoring skills
Excellent customer service, professionalism, and interpersonal communication abilities
High degree of initiative with the ability to work independently and collaboratively
Strong problem-solving and critical thinking skills
Demonstrated ability to plan, organize, prioritize, and adapt work in response to changing priorities
Legally authorized to work in the United States at the time of application

Nice To Haves

Nursing degree
Active Registered Nurse (RN) License

Responsibilities

Assist Manager with supporting an efficient department operation and workflow
Ensures workflow is efficient and effective
Works with other departments to assure workflow is adequate to meet the needs of the project/audit
Coaches staff through complex, ambiguous, or high-risk audit scenarios
Identifies and assists in resolution of escalated and/or complex issues
Supports daily operations and long-range planning for the department
Collaborates with department and all business segments to ensure that consistent, effective and timely communication occurs
Assists with data collection and audits
Develops and/or assist with training and training materials
Work with HR to recruit and hire new staff
Supports staff resilience and performance during peak audit periods
Balances productivity expectations with quality and compliance standards
Support, follow and ensure full compliance with Medica-wide policies and procedures including (but not limited to) all human resources policies, Medica's business expense policies, privacy, and compliance policies
Supports area staff through team education and 1:1 support
Conduct 1:1 meetings with direct reports, providing timely feedback, coaching, training, mentoring and performance management
Communicates accurate and timely information to team members to enhance effectiveness and efficiency of performance
Encourage staff to identify potential areas for improvement and work efficiencies, identify streamlining opportunities and work with leads and other departments for implementation of improvement opportunities
Provides ongoing coaching and development for new and existing team members on a regular basis
Monitors and adjusts team workloads as needed to complete projects/audits
Create a positive work environment, motivating achievement, minimizing non-productive and restrictive rules, set high standards and recognize and reward good work
Participates in key work projects to design, review, and support Medica’s quality initiatives and regulatory and accreditation requirements and audits
Partners with Manager, Program Manager and Project Leads to design and implement audit workflows
Oversees clinical review readiness for audits including documentation standards, reviewer training, and tool readiness
Ensures SOPs and job aids are audit ready, defensible, and operationally usable
Ensure that quality improvement programs reflect medical policy guidelines, regulatory and accreditation requirements, HEDIS & STAR measurements, RADV, correct coding and Medica’s priorities
Reviews tools and Job Aids to assure usability by staff and assures the tool/aid will meet the need of the project/audit
Oversee & assist with medical record retrieval work including remote electronic health record (EHR) access and training clinical review team
Responsible for leading the team in education to business segments/clinics/ providers/other inter-departments regarding Medica quality programs and coding practices
Leads the design of educational aides to support Providers and improve compliance.
Translates regulatory and coding requirements into practical guidance for internal teams and external partners
Serves as a clinical subject matter resource during internal, vendor, or provider discussions
Assists Director and Manager as needed to develop, introduce and support overall goals
Develops linkages with specific departments on behalf of the Clinical Review area such as Data Management, Legal, Network Management, Compliance, Pharmacy and Complementary Networks.
Communicates information to direct reports on Medica’s goals, progress, and next steps.