Sr. Quality Review Nurse

### Position Overview Clinical Quality programs are designed to enhance clinical outcomes and concierge-level service to members through review of services provided by network healthcare providers, facilities, and employees. The Senior Clinical Quality Nurse drives clinical performance through quality auditing and clinical quality of care review processes. ### Responsibilities - Perform quality audits of internal and external member, provider, and delegated vendor interactions. - Guide interrater reliability (IRR) assessments, supporting evidence-based clinical decision-making and workflow adherence. - Investigate provider and facility quality of care concerns, identifying and escalating negative performance trends for corrective action. - Consult with company partners to ensure programs meet organizational needs while following accreditation and regulatory requirements. - Present quality and performance trend data to organizational partners, delegates, and quality subcommittees. - Collaborate on corrective action plans to address identified gaps. - Ensure compliance with all applicable laws and regulations. ### Requirements - Licensed Registered Nurse with active, unrestricted license in state of residence. - Willingness to obtain additional licenses as needed. - 2+ years of experience as a Registered Nurse. - 2+ years of experience working in a clinical care setting. - Bachelor's Degree from an accredited university (BSN Preferred). - Working knowledge of health insurance/benefit concepts. - Proficiency using Google applications (Sheets, Docs, Slides, Meets). ### Preferred Qualifications - Health plan utilization management or case management experience. - Experience in healthcare quality assurance, including auditing medical records and internal documentation. - Bilingual (fluent in Spanish) to audit Spanish-language interactions. - Experience with NCQA accreditation standards, HEDIS measures, and other regulatory requirements. - CCM or MCG certification.