Registered Nurse (RN) Medicare Quality Assurance Reviewer
New
C
Clover HealthHealthcare
Remote - USAFull-TimeMiddle
Salary$92,000 — $120,000 USD
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Job Details
- Experience
- Minimum of 3 years
- Required Skills
- Quality Assurance
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, NCD, and LCD to Medicare medical necessity reviews (required).
- Quality Assurance experience (required).
- Experience in leading vendor relationships and building clinical review teams.
- Experience working in a Medicare Advantage plan (preferred).
- RN clinical experience in a hospital setting (preferred).
- Experience working remotely (preferred).
- Excellent interpersonal skills and ability to communicate with patients and colleagues.
- Ability to adjust work based on new challenges or feedback.
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.
- Perform service line clinical reviews.
- Serve as the Clinical Medical Record Review Subject Matter Expert (SME).
- Identify clinical opportunities for improvement and communicate findings to upper management.
- Track clinical performance and evaluate vendor medical reviewers.
- Provide clinical support for new medical review process implementations.
- Monitor and track CMS Medicare clinical updates and implement necessary clinical process changes.
- Collaborate with cross-functional departments.
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