Supervisor, Clinical Quality Review

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.

We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration — because success is a team sport. It's 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 Supervisor, Quality Reviewers is responsible for leading day-to-day clinical review and medical record operations supporting complex, time-sensitive regulatory audits and quality initiatives. This role provides direct supervision, coaching, and workload management for Clinical Quality Review RNs while ensuring audit deliverables, documentation standards, and regulatory timelines are met.

The Supervisor is expected to exercise independent judgment, proactively identify operational risks, resolve escalations, and adapt workflows in response to changing audit requirements, data availability, and business priorities. Performs other duties as assigned.

Successful candidates are organized, adaptable leaders who are comfortable making decisions with incomplete information, managing competing priorities, and supporting staff through complex regulatory work.

• Assist Manager with supporting an efficient department operation and workflow
  • Ensures workflow is efficient and effective
  • Works with other departments to assure workflow is adequate to meet the needs of the project/audit
  • Coaches staff through complex, ambiguous, or high-risk audit scenarios
  • Identifies and assists in resolution of escalated and/or complex issues
  • Supports daily operations and long-range planning for the department
  • Collaborates with department and all business segments to ensure that consistent, effective and timely communication occurs
  • Assists with data collection and audits
  • Develops and/or assist with training and training materials
  • Work with HR to recruit and hire new staff
  • Supports staff resilience and performance during peak audit periods
  • Balances productivity expectations with quality and compliance standards
  • Support, follow and ensure full compliance with Medica-wide policies and procedures including (but not limited to) all human resources policies, Medica's business expense policies, privacy, and compliance policies

• Conduct 1:1 meetings with direct reports, providing timely feedback, coaching, training, mentoring and performance management
• Communicates accurate and timely information to team members to enhance effectiveness and efficiency of performance
• Encourage staff to identify potential areas for improvement and work efficiencies, identify streamlining opportunities and work with leads and other departments for implementation of improvement opportunities
• Provides ongoing coaching and development for new and existing team members on a regular basis
• Monitors and adjusts team workloads as needed to complete projects/audits
• Create a positive work environment, motivating achievement, minimizing non-productive and restrictive rules, set high standards and recognize and reward good work
• Participates in key work projects to design, review, and support Medica’s quality initiatives and regulatory and accreditation requirements and audits
  • Partners with Manager, Program Manager and Project Leads to design and implement audit workflows
  • Oversees clinical review readiness for audits including documentation standards, reviewer training, and tool readiness
  • Ensures SOPs and job aids are audit ready, defensible, and operationally usable
  • Ensure that quality improvement programs reflect medical policy guidelines, regulatory and accreditation requirements, HEDIS & STAR measurements, RADV, correct coding and Medica’s priorities
  • Reviews tools and Job Aids to assure usability by staff and assures the tool/aid will meet the need of the project/audit
  • Oversee & assist with medical record retrieval work including remote electronic health record (EHR) access and training clinical review team
• Responsible for leading the team in education to business segments/clinics/ providers/other inter-departments regarding Medica quality programs and coding practices
  • Leads the design of educational aides to support Providers and improve compliance.
  • Translates regulatory and coding requirements into practical guidance for internal teams and external partners
  • Serves as a clinical subject matter resource during internal, vendor, or provider discussions
  • Assists Director and Manager as needed to develop, introduce and support overall goals
  • Develops linkages with specific departments on behalf of the Clinical Review area such as Data Management, Legal, Network Management,…