Job Description
Job Title: Quality Review Specialist (RN)
Contract Duration: 6 Months
Work Arrangement: Fully Remote — no onsite work required
Overview
The Quality Review Specialist (RN) investigates and reviews quality-of-care grievances to ensure compliance with CMS, NCQA, and state regulations. This role independently evaluates clinical cases, supports quality improvement initiatives, and collaborates with medical leadership to resolve care issues.
- Key Responsibilities
- Review and investigate quality-of-care cases (adverse events, critical incidents, never events)
- Conduct concurrent and retrospective clinical reviews
- Analyze medical records and determine grievance outcomes and severity levels
- Collaborate with Medical Directors, Physicians, and QOC leadership
- Develop and support corrective action plans
- Prepare case summaries, reports, and resolution letters
- Ensure compliance with CMS, NCQA, and accreditation standards
- Participate in inter-rater reliability and quality reporting activities
- Required Qualifications
- Active, unrestricted Registered Nurse (RN) license
- 3–5 years of quality review, quality improvement, or clinical review experience
- Knowledge of Medicare/Medicaid and healthcare quality standards
- Strong analytical, documentation, and communication skills
- Proficiency in Microsoft Office applications
- Preferred
- Experience with CMS, NCQA, HEDIS, CAHPS, HOS
- Background in Medicare Advantage
- Ability to work independently with strong attention to detail
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