Quality Review Specialist

this position is fully remote in any location

do not exceed bill rate is ***/hour

Under the supervision of the Quality-of-Care Unit Manager, the Quality Clinical Management Senior Analyst Nurse conducts case reviews and the investigation of potential quality of care grievances both externally and internally referred cases in a timely, and efficient manner. The Quality Clinical Management Senior Analyst Nurse is responsible for conducting quality improvement/management activities in accordance with state and federal regulatory requirements, including, but not limited to, Centers for Medicare and Medicaid Services (CMS), State and National Committee for Quality Assurance (NCQA).

Quality Clinical Management Senior Analyst makes independent clinical decisions on overall grievances outcomes up to LEVELING and resolutions. Experience level required: 3-5 years.

• Reviews and investigates potential quality of care (QOC) cases, which include, but are not limited to, adverse events, critical incidents and never events, both external and internal.
• Coordinates medical record requests, as appropriate, and reviews medical records to facilitate complete and thorough investigation of Medicare Advantage customers grievances.
• Works in collaboration with MME, (Physician – Medical Market Executive) and QOC Unit Manager in the investigation of quality-of-care grievance as warranted.
• Monitors quality of care issues and develops corrective action plans for areas of concern.
• Reviews and monitors high-risk, high-volume, and unusual events concurrently and retrospectively as they occur.
• Manages the occurrence reporting system ensuring timely and appropriate incident investigation, remediation and documentation.
• Prepares summary of findings, assigns severity levels to case, when appropriate, and prepares resolution letter to customers.
• Prepares and sends corrective action plans in collaboration with Medical Directors, Net ops and QOC Manager as warranted.
• Prepares case studies for presentation to National Physician Advisory Committee (NPAC).
• Assists with preparation of and may present quarterly reports to Corporate Quality Improvement Committee (CQIC) and NPAC.
• Assists in the preparation, management and presentation of other Quality activities and reports including submission of all compliance related documentation.
• Maintains performance against established targets.
• Participates in inter-rater reliability testing to ensure consistency of reviews.
• Maintains knowledge of policies and procedures and assures team performs assigned duties in accordance with applicable regulatory requirements, State and accreditation standards.
• Performs other job-related duties as required.

• Strong knowledge of common patient disease processes and usual methods of treating narrow and board spectrum disease processes.
• Thorough knowledge of medical terminology and commonly used terminology.
• Ability to effectively evaluate medical records for appropriateness to interrupt applicable care rendered or not rendered.
• Ability to assess and judge the clinical performance of physicians and other health professionals regarding care rendered or not rendered.
• Strong analytical, assessment and problem-solving skills, making sounds judgement in clinical situations
• Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards to present to all audiences.
• Intermediate skills in Word, PowerPoint, Excel, and Outlook with basic ability to enter data into and navigate through a database.
• Maintains confidentiality of all sensitive documents, records, discussions and other information generated in connection with quality-of-care activities.
• Self-directed and able to work independently. Uses appropriate judgment to seek assistance and ask questions as warranted.
• Keeps QOC Manager updated on overall activities, issues identified, and actions to address issues.
• Strong attention to detail and work accuracy required.

• Current, active and unrestricted Registered Nurse (RN) license.
• Three to five years of quality review and improvement experience preferred
• Experience with CMS, NCQA standards, HEDIS, CAHPS, HOS and quality management preferred.
• Knowledge/experience in the Medicare/Medicaid industry preferred.
• Strong project management, research and analytical skills preferred.

“Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.”