Clinical Quality Reviewer RN 3

Job Description:
Job Title: Clinical Quality Reviewer RN (Quality of Care Review)
Duration: 9+ Months (Potential Extension and Conversion to FTE)
Location: Remote - CA
Work Schedule: Monday - Friday | 8:00 AM - 4:30 PM / 5:00 PM (depending on 30-minute or 1-hour lunch)
Hours: 40 Hours per Week
Overtime: No
Max Pay Range: XXXXXXXXXXX - XXXXXXXXXXX Per hr. on w2.

Note: Candidate must reside in CA & Hold CA RN License


Position Overview


We are seeking an experienced Registered Nurse (RN) to join the Clinical Quality Review (CQR) Team . This team is responsible for investigating and reviewing Potential Quality of Care Issues (PQIs) arising from member grievances, provider concerns, and internal referrals.


The Clinical Quality Reviewer will conduct comprehensive quality reviews, evaluate clinical concerns, determine appropriate review pathways, collaborate with Medical Directors and physician committees, and support provider quality improvement initiatives. This role requires strong clinical judgment, quality review expertise, investigative skills, and the ability to work independently in a remote environment.


The position reports directly to the Manager, Clinical Quality Review and plays a critical role in ensuring quality standards, patient safety, and provider accountability are maintained.


Key Responsibilities


Clinical Quality Review & Investigation

• Analyze potential quality of care issues received from internal and external sources.
• Conduct comprehensive investigations of member grievances and provider-related quality concerns.
• Apply clinical expertise, critical thinking, and professional judgment to identify quality of care issues.
• Review clinical records, supporting documentation, and case details to determine findings.
• Evaluate whether identified concerns resulted in or had the potential to result in member harm.

Case Management & Escalation

• Determine the appropriate level of review required for each case.
• Escalate cases to Medical Directors, Peer Review Committees, and Credentialing Committees when necessary.
• Prepare cases for physician committee review and presentations.
• Manage assigned caseload while meeting all established timeliness and compliance metrics.
• Track case progress through multiple levels of review.

Provider Quality Improvement

• Develop corrective action plan requests for providers when practice improvement opportunities are identified.
• Present and discuss corrective action plan responses with Medical Directors and Peer Review Committees.
• Monitor provider responses and support quality improvement initiatives.
• Identify trends, patterns, and opportunities for clinical performance improvement.

Committee Support & Reporting

• Prepare case summaries and support documentation for committee presentations.
• Participate in physician review discussions.
• Document review findings and recommendations accurately.
• Maintain compliance with departmental policies, regulatory requirements, and quality standards.

Clinical Oversight

• Provide clinical oversight as needed.
• Collaborate with Appeals & Grievances teams and other internal departments.
• Support organizational quality initiatives and quality improvement efforts.

Required Qualifications


Education

• Associate's Degree in Nursing OR Bachelor's Degree in Nursing

Licensure

• Current, active, unrestricted California RN License

Experience

• Extensive clinical nursing experience, including hospital-based clinical experience
• Experience working in a Health Plan, Managed Care Organization, or IPA environment
• Prior remote work experience required
• Strong behavioral health knowledge for occasional coverage needs

Required Skills (Top Non-Negotiables)


1. Strong Organizational & Computer Skills

• Detail-oriented with excellent organizational abilities
• Ability to manage multiple priorities and deadlines
• Strong documentation and record review skills

2. Health Plan / IPA Experience

• Experience working remotely in a health plan, managed care, or IPA environment
• Understanding of quality review processes and healthcare regulations

3. Extensive Clinical Knowledge

• Strong clinical nursing background
• Acute care and hospital experience required
• Ability to apply clinical judgment during complex case reviews
• Behavioral health experience preferred for occasional support needs

Preferred Qualifications

• Previous Clinical Quality Review experience
• Utilization Management (UM) experience
• Case Management (CM) experience
• Experience presenting cases to physician committees
• Strong written and verbal communication skills
• Excellent case presentation and documentation skills

Software & Technical Requirements


Required Software Experience

• Microsoft Office Suite
  • Outlook
  • Word
  • Excel (Spreadsheet Management)
• Adobe Acrobat

Equipment Provided

• Standard company-issued laptop and related equipment

Disqualifiers


Candidates may not be considered if they have:

• No remote work experience
• Poor resume formatting
• Spelling or grammatical errors
• Limited computer proficiency
• Lack of managed care, health plan, or IPA experience

Team Structure


The Clinical Quality Review team currently consists of:

• 1 Director
• 1 Manager
• 1 Team Lead
• 1 Psychologist
• 6-8 Registered Nurses
• 5 Coordinators

Internal Collaboration


This role will frequently collaborate with:

• Appeals & Grievances Department
• Medical Directors
• Peer Review Committees
• Credentialing Committees
• Clinical Leadership Teams

Work Environment

• Fully Remote
• No travel required
• Independent, highly collaborative virtual environment

Interview Process


Interview Format

• Web Conference (Zoom / Microsoft Teams)
• Video Required

Interview Stages

• Two Interviews
• Combination Interview Format

Why Join This Opportunity?


This role offers an opportunity to make a direct impact on healthcare quality and patient safety while working remotely with an experienced clinical quality team. The position provides exposure to provider quality improvement initiatives, physician committee reviews, and enterprise-level quality programs, with potential opportunities for long-term employment and career growth.


Ideal Candidates: Experienced RN professionals with strong health plans, quality review, utilization management, case management, or clinical operations backgrounds who enjoy investigative work, critical thinking, and improving quality outcomes across healthcare systems