Clinical Quality Review Nurse III

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for.

Were a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration - because success is a team sport. Its our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued.

The Clinical Quality Review III role supports quality performance by conducting medical record reviews, data collection, and clinical audits across Medica's network. The position evaluates documentation accuracy, adherence to clinical standards, and compliance with regulatory and accreditation requirements, including HEDIS, STARS, CMS Cost Audit, and RADV. It applies advanced nursing and coding expertise to identify improvement opportunities and ensure the reliability of quality outcomes. This role also serves as a resource to others by sharing clinical and coding knowledge that strengthens quality review processes. RN and Certified Coder required. Performs other duties as assigned.

Key Accountabilities

Conduct Medical Record Reviews & Clinical Quality Audits

• Collect, review, and validate clinical documentation to ensure compliance with quality standards.
• Identify documentation gaps and opportunities for improvement using established criteria.
• Prepare audit findings that support quality reporting and corrective action planning.
• Maintain accurate and organized documentation of review activities.

Support Quality Programs & Data Collection

• Perform data abstraction and documentation verification for required quality measures.
• Ensure accuracy and completeness of data submitted for accreditation and ratings programs.
• Collaborate with internal partners to clarify clinical requirements and documentation needs.
• Monitor trends and raise concerns that may impact regulatory or accreditation outcomes.

Complete Audits Related to CMS Cost, HEDIS, RADV, NCQA Site Visits & Other Regulatory Requirements

• Review coded data and medical records to verify accuracy and compliance with program rules.
• Identify discrepancies and recommend corrective actions where documentation does not meet standards.
• Contribute data and insights to support audit readiness and regulatory submissions.
• Apply RN and coding expertise to ensure high-quality, compliant documentation practices.

Provide Education & Support to Providers & Internal Partners

• Deliver feedback and guidance to providers regarding documentation expectations and audit results.
• Share clinical and coding insights that improve documentation accuracy and quality outcomes.
• Assist internal teams in understanding program requirements and quality measure criteria.
• Support corrective action plans through targeted education and follow-up activities.

Contribute to Continuous Improvement of Quality Processes

• Recommend enhancements to review methods, tools, or workflows based on audit findings.
• Support process updates that improve accuracy, consistency, or efficiency.
• Share observations from clinical reviews to inform broader quality initiatives.
• Collaborate with colleagues to align practices with evolving regulatory and accreditation standards.

Required Qualifications

• Associate's or Bachelors degree in Nursing
• 5+ years of related work experience including clinical quality chart reviews, data analysis, auditing and or quality improvement experience.

Required Certifications/Licensure

• RN License required
• Current Coding Certification (CCA, CPC, CPC-P, CPC-H, CCS, CCS-P, RHIT, RHIA), or the ability to obtain the CPC or CRC coding certification within 1 year of employment (or by Medica determined timeframe).

Preferred Qualifications

• Experience and/or knowledge of HEDIS, NCQA, RADV, or other accreditation and quality measures strongly preferred.
• Knowledge of CPT and diagnosis codes strongly preferred.
• Ability to manage competing priorities and multiple deadlines.
• Demonstrated organizational and time management skills.
• Ability to make reliable independent decisions using analytical problem-solving skills.
• Strong attention to detail.
• Excellent written and verbal communication skills.
• Experience navigating electronic health records preferred.
• Proficient in use of personal computers and supporting software including but not limited to Adobe Acrobat, Windows, MS Office products (i.e. Word, Excel, Outlook, Teams, SharePoint, OneNote, OneDrive).

This position is a Remote role. To be eligible for consideration, candidates must have a primary home address located within any state where Medica is registered as an employer - AR, AZ, FL, GA, IA, IL, KS, KY, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, WI

The full salary grade for this position is $70,200 - $120,400. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $70,200 - $105,315. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the positions scope and responsibility, internal pay equity and external market salary data.  In addition to compensation, Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.

The compensation and benefits information is provided as of the date of this posting. Medica's compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.

Eligibility to work in the US: Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States.

We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.