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 assist 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
• Makes adjustments to team workloads as needed to complete projects/audits
• Creates a positive work environment, motivating achievement, minimizing non-productive and restrictive rules, sets high standards and recognizes and rewards 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:
  • Clinical Experience
  • Active Registered Nurse (RN) License preferred
  • Candidates without an RN license must possess relevant clinical licensure or credentials appropriate to their healthcare discipline and demonstrate equivalent clinical competency
  • Leadership & Professional Experience
  • Minimum 2 years of prior Lead, Supervisor, or Clinical Leadership experience
  • 4 years of broad-based nursing or clinical experience, or an equivalent depth of experience within a clinically focused healthcare discipline
  • Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
  • Regulatory, Audit, and Clinical Review Expertise
  • Demonstrated experience managing clinical review, quality, or audit work under strict regulatory timelines
  • Demonstrated experience and knowledge of regulatory medical record documentation requirements, including:HEDIS and STARSOff-Season Data CollectionCMS Cost AuditsRADV and Clinical Data Validation
  • Knowledge of ICD-10 and CPT coding
  • Operational Leadership & Decision-Making
  • Experience leading teams through frequent change and evolving requirements
  • Ability to make independent operational decisions in fast-paced, highly regulated environments
  • Demonstrated ability to balance quality, compliance, and productivity expectations
  • Data, Technology & Project Management Skills
  • Demonstrated effective project management skills, including:
  • Use of planning and tracking tools
  • Development of achievable goals, timelines, and deliverables
  • Innovative and efficient use of resources
  • Advanced computer skills, including Adobe Acrobat and Microsoft 365 applications (Word, Outlook, PowerPoint, Excel, Teams, SharePoint)
  • Communication, Team Leadership & Core Competencies
  • 3–5 years of experience communicating effectively with staff and leaders
  • Proven team-building, coaching, and mentoring skills
  • Excellent customer service, professionalism, and interpersonal communication abilities
  • High degree of initiative with the ability to work independently and collaboratively
  • Strong problem-solving and critical thinking skills
  • Demonstrated ability to plan, organize, prioritize, and adapt work in response to changing priorities

Qualifications

• Required Qualifications
• 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:
  • Active Registered Nurse (RN) License preferred
  • Candidates without an RN license must possess relevant clinical licensure or credentials appropriate to their healthcare discipline and demonstrate equivalent clinical competency
  • Leadership & Professional Experience
  • Minimum 2 years of prior Lead, Supervisor, or Clinical Leadership experience
  • 4 years of broad-based nursing or clinical experience, or an equivalent depth of experience within a clinically focused healthcare discipline
  • Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities
  • Regulatory, Audit, and Clinical Review Expertise
  • Demonstrated experience managing clinical review, quality, or audit work under strict regulatory timelines
  • Demonstrated experience and knowledge of regulatory medical record documentation requirements, including:HEDIS and STARSOff-Season Data CollectionCMS Cost AuditsRADV and Clinical Data Validation
  • Knowledge of ICD-10 and CPT coding
  • Operational Leadership & Decision-Making
  • Experience leading teams through frequent change and evolving requirements
  • Ability to make independent operational decisions in fast-paced, highly regulated environments
  • Demonstrated ability to balance quality, compliance, and productivity expectations
  • Data, Technology & Project Management Skills
  • Demonstrated effective project management skills, including:
  • Use of planning and tracking tools
  • Development of achievable goals, timelines, and deliverables
  • Innovative and efficient use of resources
  • Advanced computer skills, including Adobe Acrobat and Microsoft 365 applications (Word, Outlook, PowerPoint, Excel, Teams, SharePoint)
  • Communication, Team Leadership & Core Competencies
  • 3–5 years of experience communicating effectively with staff and leaders
  • Proven team-building, coaching, and mentoring skills
  • Excellent customer service, professionalism, and interpersonal communication abilities
  • High degree of initiative with the ability to work independently and collaboratively
  • Strong problem-solving and critical thinking skills
  • Demonstrated ability to plan, organize, prioritize, and adapt work in response to changing priorities

Benefits

This position is an Office role, which requires an employee to work onsite, on average, 3 days per week. We are open to candidates located near one of the following office locations: Minnetonka, MN, Madison, WI, Omaha, NE, or St. Louis, MO. The full salary grade for this position is $78,700 - $134,900. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $78,700 - $118,020. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to compensation, Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees. The compensation and benefits information is provided as of the date of this posting. Medica’s compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.