Quality of Care and Clinical Review Nurse

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Job Summary

Under the supervision of the Quality of Care (QOC) Manager, the QOC Nurse conducts the review and investigation of potential quality of care issues in a timely, and efficient manner. The QOC Nurse is responsible for conducting quality improvement/management activities in accordance with state and federal regulatory requirements, including, but not limited to, Centers for Medicare and Medicaid Services (CMS), State and National Committee for Quality Assurance (NCQA).

Required Job Qualifications

• Registered Nurse (RN) with unrestricted license in state of operations.
• 5 years combined knowledge of healthcare processes.
• Knowledge of managed care processes.
• Organizational skills and ability to meet deadlines and manage multiple priorities.
• Verbal and written communication skills to include interfacing with staff across organizational lines plus interfacing with members and providers.
• PC experience to include Microsoft Word, Access, and Excel.

• Strong knowledge of common patient disease processes and usual methods of treating them;
• Thorough knowledge of medical terminology and commonly used equipment;
• Ability to effectively evaluate medical records for appropriateness of care;
• Ability to assess and judge the clinical performance of physicians and other health professionals;
• Strong analytical, assessment and problem-solving skills;
• Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards;
• Intermediate skills in Word, PowerPoint, Excel, and Outlook with basic ability to enter data into and navigate through a database;
• Maintains confidentiality of all sensitive documents, records, discussions and other information generated in connection with quality of care activities;
• Self-directed and able to work independently. Uses appropriate judgment to seek assistance and ask questions ;
• Keeps QOC Manager updated on overall activities, issues identified, and actions to address issues;
• Strong attention to detail and work accuracy;

Preferred Job Qualifications

• Exceptional presentation and facilitation skills, with demonstrated experience presenting quality, clinical, operational, or regulatory findings to leadership, providers, committees, and cross-functional stakeholders.
• Strong investigative skills with experience conducting clinical reviews, quality of care investigations, root cause analysis, and issue resolution.
• Experience developing and delivering training, educational sessions, or presentations to internal and external audiences.
• Experience interpreting, summarizing, and communicating complex clinical information, trends, and findings in a clear and concise manner.
• Experience with Quality of Care (QOC), Quality Management, Quality Improvement, Patient Safety, Risk Management, Appeals, Grievances, or related clinical quality programs.
• Knowledge of CMS, NCQA, Medicare, Medicaid, and other regulatory requirements related to quality of care reviews and investigations.
• Demonstrated ability to identify trends, develop recommendations, and present actionable solutions to improve quality outcomes and member experience.

Sponsorship is not available

This is a remote role

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Pay Transparency Statement:

At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees. Learn more about our benefit offerings by visiting .

The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan.

This position may be performed remotely from anywhere within the continental United States, excluding California, New York, Alaska, and Hawaii.

HCSC Employment Statement:

We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics. We are a drug-free and smoke-free workplace. Employment may be contingent upon successful completion of drug screening in accordance with applicable law.

Base Pay Range

$69,800.00 - $125,900.00

Exact compensation may vary based on skills, experience, and location.

Originally posted on Himalayas