Job Title: Quality Review Specialist (RN)
Contract Duration: 6 Months
Work Arrangement: Fully Remote — no onsite work required
Overview
The Quality Review Specialist (RN) investigates and reviews quality-of-care grievances to ensure compliance with CMS, NCQA, and state regulations. This role independently evaluates clinical cases, supports quality improvement initiatives, and collaborates with medical leadership to resolve care issues.
Key Responsibilities
Review and investigate quality-of-care cases (adverse events, critical incidents, never events)
Conduct concurrent and retrospective clinical reviews
Analyze medical records and determine grievance outcomes and severity levels
Collaborate with Medical Directors, Physicians, and QOC leadership
Develop and support corrective action plans
Prepare case summaries, reports, and resolution letters
Ensure compliance with CMS, NCQA, and accreditation standards
Participate in inter-rater reliability and quality reporting activities
Required Qualifications
Active, unrestricted Registered Nurse (RN) license
3–5 years of quality review, quality improvement, or clinical review experience
Knowledge of Medicare/Medicaid and healthcare quality standards
Strong analytical, documentation, and communication skills
Proficiency in Microsoft Office applications
Preferred
Experience with CMS, NCQA, HEDIS, CAHPS, HOS
Background in Medicare Advantage
Ability to work independently with strong attention to detail