Supervisor, Clinical Quality Review

About the role

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.

Responsibilities

• Assists 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
• Performs data collection and audits
• Develops and/or assists with training and training materials
• Supports staff recruitment and hiring
• Supports staff resilience and performance during peak audit periods
• Balances productivity expectations with quality and compliance standards
• Supports, follows, and ensures 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
• Supports area staff through team education and 1:1 support
• Conducts 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
• Encourages staff to identify potential areas for improvement and work efficiencies, identifies streamlining opportunities and works 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
• Maintains 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
• Ensures 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
• Oversees & assists 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
• 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, Compliance, Pharmacy and Complementary Networks
• Communicates information to direct reports on Medica’s goals, progress, and next steps

Requirements

• Bachelor's degree or equivalent experience in a related field (Nursing preferred)
• 5 years of relevant clinical healthcare experience beyond degree, including broad-based clinical practice or equivalent clinical review experience
• Skills and Abilities:
  • Regulatory, Audit, and Clinical Review Expertise
  • Operational Leadership & Decision-Making
  • Data, Technology & Project Management Skills
  • Communication, Team Leadership & Core Competencies

Qualifications

• Minimum 2 years of prior Lead, Supervisor, or Clinical Leadership experience
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
• Minimum 2 years of experience in