Registered Nurse

Registered Nurse (RN) - Clinical Quality Reviewer

Location: Remote (Must reside in California)

Schedule: Monday-Friday, 8:00 AM-4:30 PM or 8:00 AM-5:00 PM

Duration: 9-Month Contract (Strong Potential for Extension)

We are seeking an experienced Registered Nurse to join the Clinical Quality Review team. This fully remote role is responsible for investigating and reviewing potential quality of care concerns identified through member grievances and internal referrals. The Clinical Quality Reviewer plays a key role in ensuring quality standards are met while identifying opportunities for provider education and improvement.

Responsibilities

• Review and analyze potential quality of care concerns from internal and external sources
• Investigate cases using clinical judgment and critical thinking to determine if quality issues exist
• Determine the appropriate level of review and escalate cases to Medical Directors, Peer Review Committees, or Credentialing Committees as needed
• Prepare cases for presentation to physician committees
• Develop corrective action plan requests when provider practice improvements are warranted
• Present corrective action plan responses and recommendations to leadership and review committees
• Manage assigned caseload while meeting established turnaround times and performance metrics
• Provide clinical oversight support as needed

Qualifications

• Active California Registered Nurse (RN) license
• Strong clinical background, including hospital-based experience
• Experience working in a health plan or IPA environment
• Previous experience working remotely
• Excellent organizational skills, attention to detail, and computer proficiency
• Strong communication and case presentation skills

Preferred Qualifications

• Previous Quality Review experience
• Utilization Management (UM) experience
• Case Management (CM) experience
• Behavioral Health experience or exposure

If you are an experienced RN with a background in health plan operations, quality review, utilization management, or case management, we'd love to hear from you.

Job Type & Location: This is a Contract to Hire position based out of Modesto, CA.

Pay and Benefits: The pay range for this position is $45.00 - $48.00/hr. Individual compensation offered for this position within this range will depend on many factors, including qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors. Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: Medical, dental & vision; Critical Illness, Accident, and Hospital; 401(k) Retirement Plan Pre-tax and Roth post-tax contributions available; Life Insurance (Voluntary Life & AD&D for the employee and dependents); Short and long-term disability; Health Spending Account (HSA); Transportation benefits; Employee Assistance Program; Time Off/Leave (PTO, Vacation or Sick Leave).

Workplace Type: This is a fully remote position.

Application Deadline: This position is anticipated to close on Sep 28, 2026.