Job Title: Clinical Quality Reviewer RN (Quality of Care Review)
Duration: 12 Months (Potential Extension and Conversion to FTE)
Location: Remote - California Candidates Only
Work Schedule: Monday Friday | 8:00 AM 4:30 PM / 5:00 PM PST (depending on 30-minute or 1-hour lunch)
Hours: 40 Hours per Week
Max Pay Range: XXXXXXXXXXX - XXXXXXXXXXX Per hr. on w2.
Position Overview
We are seeking an experienced Registered Nurse (RN) to join the Clinical Quality Review (CQR) Team. This team is responsible for investigating and reviewing Potential Quality of Care Issues (PQIs) arising from member grievances, provider concerns, and internal referrals.
The Clinical Quality Reviewer will conduct comprehensive quality reviews, evaluate clinical concerns, determine appropriate review pathways, collaborate with Medical Directors and physician committees, and support provider quality improvement initiatives. This role requires strong clinical judgment, quality review expertise, investigative skills, and the ability to work independently in a remote environment.
The position reports directly to the Manager, Clinical Quality Review and plays a critical role in ensuring quality standards, patient safety, and provider accountability are maintained.
Key Responsibilities
Clinical Quality Review & Investigation
- Analyze potential quality of care issues received from internal and external sources.
- Conduct comprehensive investigations of member grievances and provider-related quality concerns.
- Apply clinical expertise, critical thinking, and professional judgment to identify quality of care issues.
- Review clinical records, supporting documentation, and case details to determine findings.
- Evaluate whether identified concerns resulted in or had the potential to result in member harm.
Case Management & Escalation
- Determine the appropriate level of review required for each case.
- Escalate cases to Medical Directors, Peer Review Committees, and Credentialing Committees when necessary.
- Prepare cases for physician committee review and presentations.
- Manage assigned caseload while meeting all established timeliness and compliance metrics.
- Track case progress through multiple levels of review.
Provider Quality Improvement
- Develop corrective action plan requests for providers when practice improvement opportunities are identified.
- Present and discuss corrective action plan responses with Medical Directors and Peer Review Committees.
- Monitor provider responses and support quality improvement initiatives.
- Identify trends, patterns, and opportunities for clinical performance improvement.
Committee Support & Reporting
- Prepare case summaries and support documentation for committee presentations.
- Participate in physician review discussions.
- Document review findings and recommendations accurately.
- Maintain compliance with departmental policies, regulatory requirements, and quality standards.
Clinical Oversight
- Provide clinical oversight as needed.
- Collaborate with Appeals & Grievances teams and other internal departments.
- Support organizational quality initiatives and quality improvement efforts.
Required Qualifications
Education
- Associate's Degree in Nursing OR Bachelor's Degree in Nursing
Licensure
- Current, active, unrestricted California RN License
Experience
- Extensive clinical nursing experience, including hospital-based clinical experience
- Experience working in a Health Plan, Managed Care Organization, or IPA environment
- Prior remote work experience required
- Strong behavioral health knowledge for occasional coverage needs
Required Skills (Top Non-Negotiables)
1. Strong Organizational & Computer Skills
- Detail-oriented with excellent organizational abilities
- Ability to manage multiple priorities and deadlines
- Strong documentation and record review skills
2. Health Plan / IPA Experience
- Experience working remotely in a health plan, managed care, or IPA environment
- Understanding of quality review processes and healthcare regulations
3. Extensive Clinical Knowledge
- Strong clinical nursing background
- Acute care and hospital experience required
- Ability to apply clinical judgment during complex case reviews
- Behavioral health experience preferred for occasional support needs
Preferred Qualifications
- Previous Clinical Quality Review experience
- Utilization Management (UM) experience
- Case Management (CM) experience
- Experience presenting cases to physician committees
- Strong written and verbal communication skills
- Excellent case presentation and documentation skills
Software & Technical Requirements
Required Software Experience
- Microsoft Office Suite
- Outlook
- Word
- Excel (Spreadsheet Management)
- Adobe Acrobat
Equipment Provided
- Standard company-issued laptop and related equipment
Disqualifiers
Candidates may not be considered if they have:
- Poor resume formatting
- Spelling or grammatical errors
- Limited computer proficiency
- Lack of managed care, health plan, or IPA experience
Team Structure
The Clinical Quality Review team currently consists of:
- 1 Director
- 1 Manager
- 1 Team Lead
- 1 Psychologist
- 6 8 Registered Nurses
- 5 Coordinators
Internal Collaboration
This role will frequently collaborate with:
- Appeals & Grievances Department
- Medical Directors
- Peer Review Committees
- Credentialing Committees
- Clinical Leadership Teams
Work Environment
- Fully Remote
- No travel required
- Independent, highly collaborative virtual environment
Interview Process
Interview Format
- Web Conference (Zoom / Microsoft Teams)
- Video Required
Interview Stages
- Two Interviews
- Combination Interview Format
Why Join This Opportunity?
This role offers an opportunity to make a direct impact on healthcare quality and patient safety while working remotely with an experienced clinical quality team. The position provides exposure to provider quality improvement initiatives, physician committee reviews, and enterprise-level quality programs, with potential opportunities for long-term employment and career growth.
Ideal Candidates: Experienced RN professionals with strong health plans, quality review, utilization management, case management, or clinical operations backgrounds who enjoy investigative work, critical thinking, and improving quality outcomes across healthcare systems.