Registered Nurse (RN) Medicare Quality Assurance Reviewer

As a Registered Nurse (RN) Medicare Quality Assurance Reviewer, you will:

• 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.

Success in this role looks like:

• By the end of your first 90 days:
  • Build a strong foundation in Clover’s utilization management, quality assurance, and clinical review processes.
  • Develop proficiency in Medicare regulations, clinical review requirements, and Clover’s quality standards.
  • Establish effective working relationships with internal stakeholders, vendors, and Medical Directors.
  • Consistently perform quality assurance reviews with accuracy, sound clinical judgment, and attention to compliance requirements.
• By 6 months:
  • Independently manage quality assurance responsibilities across utilization management service lines.
  • Serve as a reliable clinical resource for quality, compliance, and review-related questions.
  • Contribute to process improvements by identifying opportunities to enhance quality, consistency, and operational effectiveness.
  • Partner effectively with vendors, Medical Directors, and cross-functional teams to support quality outcomes and regulatory compliance.
• Future state:
  • Be recognized as a trusted clinical quality and utilization management subject matter expert.
  • Drive continuous improvement through trend analysis, performance insights, and recommendations that strengthen quality and compliance programs.
  • Support the evolution of clinical review processes, technology-enabled solutions, and operational initiatives that improve efficiency and member outcomes.
  • Influence organizational success by maintaining high standards of clinical excellence, regulatory compliance, and collaborative partnership across the organization.

You should get in touch if:

• You have an active and valid RN license; required.