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