RN Quality Review Analyst (Medicare / CMS / NCQA)
Job Title: Quality Review Specialist (RN)
Contract Duration: 6 Months
Work Arrangement: Fully Remote — no onsite work required
Overview
The Quality Review Specialist (RN) investigates and reviews quality-of-care grievances to ensure compliance with CMS, NCQA, and state regulations. This role independently evaluates clinical cases, supports quality improvement initiatives, and collaborates with medical leadership to resolve care issues.
Key Responsibilities
- Review and investigate quality-of-care cases (adverse events, critical incidents, never events)
- Conduct concurrent and retrospective clinical reviews
- Analyze medical records and determine grievance outcomes and severity levels
- Collaborate with Medical Directors, Physicians, and QOC leadership
- Develop and support corrective action plans
- Prepare case summaries, reports, and resolution letters
- Ensure compliance with CMS, NCQA, and accreditation standards
- Participate in inter-rater reliability and quality reporting activities
Required Qualifications
- Active, unrestricted Registered Nurse (RN) license
- 3–5 years of quality review, quality improvement, or clinical review experience
- Knowledge of Medicare/Medicaid and healthcare quality standards
- Strong analytical, documentation, and communication skills
- Proficiency in Microsoft Office applications
Preferred
- Experience with CMS, NCQA, HEDIS, CAHPS, HOS
- Background in Medicare Advantage
- Ability to work independently with strong attention to detail