Clinical Quality Reviewer- RN
Job Summary
The Clinical Quality Reviewer investigates and evaluates potential quality of care issues (PQIs) arising from member grievances and internal referrals. This role determines whether a quality concern resulted in, or had the potential to result in, member harm and identifies provider practice patterns that fall outside accepted standards. The reviewer conducts case reviews according to department protocols, coordinates appropriate levels of review, and executes follow-up actions.
Responsibilities
- Analyze quality of care issues from both internal and external sources.
- Thoroughly investigate cases, applying critical thinking and clinical judgment to identify quality of care concerns.
- Determine the appropriate level of case review, including escalation to a medical director, Peer Review Committee, or Credentialing Committee for final determination.
- Prepare cases for presentation at physician committees as indicated.
- Develop corrective action plan requests for cases where provider practice changes are needed.
- Present and discuss corrective action plan responses with the medical director and/or Peer Review Committee.
- Manage assigned caseload to meet all timeliness and documentation requirements.
- Perform clinical oversight as needed.
Requirements
- Associate’s or Bachelor’s degree in Nursing.
- Current unencumbered RN license.
- At least 2 years of experience working in an Agile or fast-paced environment.
- At least 3 years of case management experience.
- Previous quality review experience.
- Strong Clinical Background
- Strong organizational skills, computer proficiency, and attention to detail.
Summary Qualification
- Registered Nurse with formal nursing education (Associate’s or Bachelor’s degree).
- Demonstrated experience in case management and quality review.
- Proven ability to analyze clinical information and apply clinical judgment.
- Experience working within structured review processes and committees.
- Proficient with standard office software and documentation tools.
Skill
- Extensive clinical knowledge and experience, including hospital settings and behavioral health.
- Experience in health plan or IPA environments, including remote work settings.
- Utilization management (UM) or care/case management (CM) experience.
- Excellent verbal and written communication and case presentation skills.
- Strong organizational skills and attention to detail.
- Proficiency with Microsoft Office (including Excel) and Adobe Acrobat.
Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one’s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one’s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.
Pay: $48.00 - $49.50 per hour
Benefits:
- Dental insurance
- Health insurance
- Vision insurance
Work Location: Remote
