Remote Clinical Review RN

Clinical Quality Review Nurse

This role focuses on reviewing and investigating potential quality of care issues arising from member grievances and internal referrals. You will apply your clinical expertise and critical thinking to assess potential quality problems, determine appropriate levels of review, and support provider performance improvement. The position combines clinical quality review, utilization review, and discharge planning oversight in a fully remote environment with occasional on-site presence if needed.

Responsibilities

• Investigate and review potential quality of care issues (PQIs) arising from member grievances and internal referrals in accordance with department protocols.
• Analyze quality issues from both internal and external sources to identify patterns, trends, and opportunities for improvement.
• Apply critical thinking and clinical judgment to thoroughly assess whether quality of care concerns resulted in, or had the potential to result in, harm to members.
• Determine the appropriate level of case review, including when to escalate cases to a Medical Director, Peer Review Committee, or Credentialing Committee for final determination.
• Prepare detailed case summaries and documentation for presentation at physician committees as needed.
• Develop and prepare corrective action plan requests when providers need to implement changes to their current practice to address identified quality issues.
• Present and discuss corrective action plan responses with the Medical Director and/or Peer Review Committee to ensure appropriate follow-up and monitoring.
• Manage an assigned case load to meet all timeliness requirements and performance expectations.
• Perform prospective, concurrent, and retrospective utilization reviews and first-level determination approvals for members using evidence-based guidelines, including BSC and CMS guidelines and nationally recognized clinical criteria for Medicare lines of business.
• Conduct clinical review of claims to assess medical necessity, coding accuracy, medical policy compliance, and contract compliance.
• Ensure discharge planning at levels of care appropriate for member needs and acuity, including determining post-acute needs such as levels of care, durable medical equipment, and post-service needs to support quality and cost-appropriate discharge plans.
• Prepare and present cases to the Medical Director for oversight and medical necessity determinations, and communicate determinations to providers and/or members in compliance with state, federal, and accreditation requirements.
• Develop and review member-centered documentation and correspondence that accurately reflect determinations and comply with regulatory and accreditation standards.
• Identify potential quality of care issues, service delays, or treatment delays and intervene as clinically appropriate.
• Refer members to Case Management when there are acute inpatient needs that may affect discharge planning.
• Attend staff meetings, clinical rounds, and weekly huddles to collaborate with colleagues and stay aligned with departmental processes and updates.
• Maintain required quality and productivity metrics for all assigned casework.
• Serve as a buddy or support resource for new employees, helping them integrate into workflows and processes.
• Maintain a HIPAA-compliant workspace in a telework environment and adhere to all privacy and security requirements.
• Utilize electronic medical records (EMR) and clinical criteria tools such as MCG to support utilization management and clinical decision-making.

Essential Skills

• Current and active California Registered Nurse (RN) license.
• At least 5 years of prior relevant clinical or utilization management experience.
• Strong background in acute care and inpatient care settings.
• Experience providing direct patient care and applying clinical judgment in complex situations.
• Proficiency in performing prospective, concurrent, and retrospective utilization reviews.
• Ability to conduct first-level determination approvals using BSC and CMS evidence-based guidelines, policies, and nationally recognized clinical criteria for Medicare lines of business.
• Demonstrated experience in clinical review of claims…