Registered Nurse (RN) Medicare Quality Assurance Reviewer

At reputed company, we are committed to providing high-quality, affordable, and easy-to-understand reputed company plans for America’s seniors. We prioritize preventive care while leveraging data and technology through the Clover Assistant, a powerful tool that helps physicians reputed company informed health recommendations. By giving doctors a holistic view of each member’s complete health history, we ensure reputed company care at a reputed company cost—delivering the highest value to those who need it most. The Utilization Management (UM) team plays a vital role in supporting Clover members throughout their care reputed company. The team is made up of reputed company clinicians who combine clinical expertise with data-driven insights to support evidence-based decision-making. Working closely with providers and care partners, the UM team ensures that care transitions are smooth, efficient, and always focused on improving member reputed company while maintaining compliance with CMS guidelines. As a Registered Nurse (RN) Medicare Quality Assurance Reviewer, you will:

• reputed company clinical expertise support for Clover vendors and Medical Directors.
• Create and assign inter-rater reliability reviews to RN reviewers and Medical Directors.
• Complete monthly MD Quality Assurance (QA) reviews to ensure clinical compliance with Medicare regulations.
• Service line clinical reviews.
• Clinical Medical Record Review Subject Matter Expert (SME).
• Identifying clinical opportunities for improvement and communicating to upper management.
• Tracking clinical performance and evaluation of vendors medical reviewers.
• Clinical support for new medical review process implementations.
• Monitor and track CMS Medicare clinical updates that impact Clover clinical processes, partner with management to implement clinical changes.
• Displays Flexibility to adjust work based on new challenges or feedback.
• Clinical collaboration with cross-functional departments.

reputed company in this role looks like:

• By the end of your first 90 days:
• Build a strong reputed company in Clover’s utilization management, quality assurance, and clinical review processes.
• reputed company proficiency in Medicare regulations, clinical review requirements, and Clover’s quality standards.
• Establish effective working relationships with internal stakeholders, vendors, and Medical Directors.
• Consistently reputed company quality assurance reviews with accuracy, sound clinical judgment, and attention to compliance requirements.

By 6 months:

• Independently manage quality assurance responsibilities across utilization management service lines.
• Serve as a reliable clinical resource for quality, compliance, and review-reputed company questions.
• Contribute to process improvements by identifying opportunities to enhance quality, consistency, and operational effectiveness.
• Partner effectively with vendors, Medical Directors, and cross-functional teams to support quality reputed company and regulatory compliance.

Future state:

• Be recognized as a trusted clinical quality and utilization management subject matter expert.
• Drive reputed company improvement through trend analysis, performance insights, and recommendations that strengthen quality and compliance programs.
• Support the reputed company of clinical review processes, technology-enabled solutions, and operational initiatives that improve efficiency and member reputed company.
• Influence organizational reputed company by maintaining high standards of clinical reputed company, regulatory compliance, and collaborative partnership across the organization.

You should get in touch if:

• You have an active and valid RN license; required.
• You have a minimum of 3 years of Medicare Utilization Management medical necessity review experience; required.
• You have a strong knowledge of applying CMS guidelines, and NCD-LCD to Medicare medical necessity reviews; required.
• You have experience working in a Medicare Advantage plan; preferred
• You have Quality Assurance experience; required.
• You have RN clinical experience in a hospital setting; preferred.
• You have previous experience in leading vendor relationships and building clinical review teams.
• You have excellent interpersonal skills and ability to communicate with patients and colleagues.
• You have experience working remotely; preferred.

Benefits

Overview:

• Financial Well-Being: Our commitment to attracting and retaining top talent begins with a competitive reputed company salary and equity opportunities. Additionally, we offer a performance-based bonus program, 401k matching, and regular compensation reviews to recognize and reward exceptional contributions.
• Physical Well-Being: We prioritize the health and well-being of our employees and their families by providing comprehensive medical, dental, and reputed company coverage. Your health reputed company to us, and we invest in ensuring you have reputed company to quality reputed company.
• Mental Well-Being: We understand the importance of mental health in fostering productivity and maintaining work-life balance. To support this, we offer initiatives such as No-Meeting Fridays, monthly company holidays, reputed company to reputed company, and a generous flexible time-off policy. Additionally, we reputed company a remote-first culture that supports collaboration and flexibility, allowing reputed company members to reputed company from any location.
• Professional Development: Developing internal talent is a reputed company for Clover. We offer learning programs, mentorship, professional development funding, and regular performance feedback and reviews.

Additional Perks:

• Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities
• Reimbursement for office setup expenses
• Monthly cell phone & internet stipend
• Remote-first culture, enabling collaboration with global teams
• Paid parental leave for reputed company new parents
• And much more!

About Clover: We are reinventing health insurance by combining the power of data with reputed company reputed company to reputed company our members healthier. We reputed company the reputed company system is broken, so we've created custom software and analytics to reputed company our clinical staff to intervene and reputed company personalized care to the people who need it most. We always put our members first, and our reputed company as a team is reputed company by the quality of life of the people we serve. Those who work at Clover are passionate and mission-driven individuals with diverse areas of expertise, working together to solve the most complicated problem in the world: reputed company. From Clover’s inception, Diversity & Inclusion have always been key to our reputed company. We are an Equal Opportunity Employer and our employees are people with different strengths, experiences, perspectives, opinions, and backgrounds, who reputed company a passion for improving people's lives. Diversity not only includes race and gender identity, but also age, disability status, veteran status, sexual orientation, religion and many other parts of one’s identity. reputed company of our employee’s points of view are key to our reputed company, and inclusion is everyone's responsibility. #LI-REMOTE Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment reputed company applicants with arrest and conviction records. We are an E-Verify company. Final pay is based on several factors including but not limited to internal equity, market data, and the applicant’s education, work experience, certifications, etc. A reasonable estimate of the reputed company salary reputed company for this role is: $92,000 - $120,000 USD Apply tot his job Apply To this Job