Clinical Quality Review Nurse

Job Overview

Reporting directly to the Team Lead of Clinical Quality and Record Review, this role independently collaborates with internal departments and external vendors to monitor, investigate, and resolve clinical quality concerns per TRICARE and plan standards. The position primarily involves meticulous post-service clinical assessments across all care environments to elevate service delivery quality.

Key Responsibilities

• Apply clinical expertise to perform retrospective case reviews identifying deviations from care standards or care gaps, and ensure inclusion of mandatory data elements, documenting findings in internal tracking tools.
• Conduct thorough clinical literature reviews and summarize relevant conclusions.
• Communicate with healthcare providers and facilities to obtain necessary records for comprehensive case evaluations and final determinations.
• Perform chart reviews and audits both electronically and onsite at medical offices.
• Extract pertinent data aligned with review objectives.
• Compose precise investigative summaries and quality review determination letters.
• Establish and maintain cooperative relationships with internal colleagues, external stakeholders, and vendors.
• Safeguard confidentiality of all medical documentation and correspondence.
• Adhere to stringent deadlines effectively.
• Recognize and report suspected fraudulent activities pertaining to healthcare services.
• Assist in clinical data collection and analysis for reporting purposes, including monthly quality issues and annual clinical quality management programs.
• Support data presentation efforts in peer review and quality committee settings.
• Analyze data trends to inform quality improvement initiatives.
• Engage in continuous quality improvement and root cause analyses to address identified service issues.
• Cross-train and assume additional duties within the Quality department as needed.
• Participate actively in meetings aimed at meeting departmental and organizational goals.

Experience and Skills Requirements

• Minimum five years’ experience in healthcare quality management.
• At least five years of clinical nursing practice.
• Experience in quality assurance or improvement within managed health plans, integrated healthcare systems, or regulatory bodies.
• Proficiency in abstracting and analyzing medical records and clinical data.
• Strong analytical, organizational, and problem-solving capabilities.
• Ability to work independently and collaboratively within teams.
• Excellent project management skills.
• Intermediate expertise in statistical analysis and data interpretation.
• Effective communication skills, both verbal and written, to interact with diverse teams.
• Capacity to manage caseloads aligned with performance standards.
• Outstanding customer service orientation.
• Good understanding of medical terminology, anatomy, physiology, and disease concepts; foundational knowledge of ICD-10, CPT, and HCPCS coding.
• Familiarity with Medicare, Medicaid, and TRICARE systems.
• Proficient in Microsoft Office Suite (Excel, Outlook, PowerPoint, Word); experience with Access and Visio valued.
• Strong clinical decision-making skills to identify quality issues and recommend corrective measures.

Education and Licensing

• Active and unrestricted RN or LPN/LVN license valid in CT, NJ, NY, or PA required.
• Bachelor’s degree (BA, BS, or BSN) preferred.

Compensation and Benefits

Licensed Practical Nurse/Vocational Nurse (LPN/LVN) salary ranges between $80,000 and $85,000 annually. Registered Nurse (RN) salary ranges between $107,000 and $115,000 annually.

The employer offers comprehensive benefits including medical coverage with no deductible for in-network services, vision and dental insurance, life and disability insurance at no cost, commuter benefits, tuition reimbursement, and a fully vested 401(k) plan with employer matching from day one. Additional perks include generous paid time off (vacation, ten holidays, and three personal days), access to employee assistance programs, and exclusive discount opportunities.

Equal Opportunity Employer Statement

The employer is an equal opportunity organization committed to inclusive hiring practices, ensuring all qualified applicants receive fair consideration without discrimination based on veteran status, disability, or legally protected characteristics.