Medica’s Clinical Quality Review Nurse works as part of a team to support various audits and quality initiatives. The Clinical Quality Review Nurse performs medical record data collection and abstraction, conducts quality reviews, and audits to ensure quality performance within Medica’s network.

Quality improvement projects include but are not limited to, HEDIS/STARs, Supplemental Data collection, Care Gap Closure, Cost audits, Risk Adjustment Data Validation, and other reviews to assist with meeting regulatory and internal requirements.

Qualifications

• Associate or bachelor’s degree in nursing.
• 5+ years of experience including clinical quality chart reviews, data analysis, auditing and or quality improvement experience.
• Experience and/or knowledge of HEDIS, NCQA, RADV, or other accreditation and quality measures strongly preferred.
• Knowledge of CPT and diagnosis codes strongly preferred.

Certifications/Licensure:

• Current RN License required.
• Current Coding Certification (CCA, CPC, CPC-P, CPC-H, CCS, CCS-P, RHIT, RHIA), or the ability to obtain the CPC or CRC coding certification within 1 year of employment (or by Medica determined timeframe).

Skills and Abilities:

• Proficient in use of personal computers and supporting software including but not limited to Adobe Acrobat, Windows, MS Office products (i.e. Word, Excel, Outlook, Teams, SharePoint, OneNote, OneDrive).
• Ability to manage competing priorities and multiple deadlines.
• Demonstrated organizational and time management skills.
• Ability to make reliable independent decisions using analytical problem-solving skills.
• Strong attention to detail
• Excellent written and verbal communication skills
• Experience navigating electronic health records preferred.

This position is a Remote role. The employee must be located in any state in which Medica is an employer and will work remotely 100% of the time.

The full salary range for this position is $67,100 - $115,100. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to compensation, Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.

The compensation and benefits information is provided as of the date of this posting. Medica’s compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.

Medica's commitment to diversity, equity and inclusion (DEI) includes unifying our workforce through learning and development, recruitment and retention. We consistently communicate the importance of DEI, celebrate achievements, and seek out community partnerships and diverse suppliers that are representative of everyone in our community. We are developing sustainable programs and investing time, talent and resources to ensure that we are living our values. We are an Equal Opportunity/Affirmative Action employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)