Registered Nurse, Medicare Quality Assurance Reviewer

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.
• Service line clinical reviews.
• Clinical Medical Record Review Subject Matter Expert (SME).
• Identifying clinical opportunities for improvement and communicating to upper management.
• Tracking clinical performance and evaluation of vendors medical reviewers.
• Clinical support for new medical review process implementations.
• Monitor and track CMS Medicare clinical updates that impact Clover clinical processes, partner with management to implement clinical changes.
• Displays flexibility to adjust work based on new challenges or feedback.
• Clinical collaboration with cross‑functional departments.

Requirements

• You have an active and valid RN license; required.
• You have a minimum of 3 years of Medicare Utilization Management medical necessity review experience; required.
• You have a strong knowledge of applying CMS guidelines, and NCD-LCD to Medicare medical necessity reviews; required.
• You have experience working in a Medicare Advantage plan; preferred.
• You have Quality Assurance experience; required.
• You have RN clinical experience in a hospital setting; preferred.
• You have previous experience in leading vendor relationships and building clinical review teams.
• You have excellent interpersonal skills and ability to communicate with patients and colleagues.
• You have experience working remotely; preferred.