Supervisor, Clinical Quality Review

Medica•St. Louis, MO

8h•Hybrid

About The Position

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for. We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration — because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued. The Supervisor, Quality Reviewers is responsible for leading day-to-day clinical review and medical record operations supporting complex, time-sensitive regulatory audits and quality initiatives. This role provides direct supervision, coaching, and workload management for Clinical Quality Review RNs while ensuring audit deliverables, documentation standards, and regulatory timelines are met. The Supervisor is expected to exercise independent judgment, proactively identify operational risks, resolve escalations, and adapt workflows in response to changing audit requirements, data availability, and business priorities. Performs other duties as assigned. Successful candidates are organized, adaptable leaders who are comfortable making decisions with incomplete information, managing competing priorities, and supporting staff through complex regulatory work.

Requirements

Bachelor's degree or equivalent experience in a related field (Nursing preferred)
5 years of relevant clinical healthcare experience beyond degree, including broad-based clinical practice or equivalent clinical review experience
Clinical Experience
Active Registered Nurse (RN) License preferred
Candidates without an RN license must possess relevant clinical licensure or credentials appropriate to their healthcare discipline and demonstrate equivalent clinical competency
Leadership & Professional Experience
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
Regulatory, Audit, and Clinical Review Expertise
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
Operational Leadership & Decision-Making
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
Data, Technology & Project Management Skills
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)
Communication, Team Leadership & Core Competencies
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

Responsibilities

Assist Manager with supporting an efficient department operation and workflow
Supports area staff through team education and 1:1 support
Participates in key work projects to design, review, and support Medica’s quality initiatives and regulatory and accreditation requirements and audits
Responsible for leading the team in education to business segments/clinics/ providers/other inter-departments regarding Medica quality programs and coding practices