Registered Nurse Quality Assurance Reviewer

Job Summary

To support Clover's commitment to high-quality healthcare, the remote Registered Nurse Quality Assurance Reviewer will provide clinical expertise, manage quality assurance reviews for Medicare compliance, and collaborate with cross-functional teams to enhance clinical processes.

Key responsibilities

• Provide clinical expertise support for vendors and Medical Directors while completing monthly quality assurance reviews
• Track clinical performance and implement clinical changes based on CMS Medicare updates
• Identify clinical opportunities for improvement and communicate findings to upper management

Required qualifications

• Active and valid RN license
• Minimum of 3 years of Medicare Utilization Management medical necessity review experience
• Strong knowledge of CMS guidelines and NCD-LCD applications
• Quality Assurance experience
• Experience working in a Medicare Advantage plan (preferred)