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Supervisor, Clinical Quality Review
Medica
Omaha, UAE
Full Time
Manager
Hybrid
3 weeks ago
Clinical ReviewRegulatory ComplianceHEDISSTARSRADVICD 10
Free
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Clinical ReviewRegulatory ComplianceHEDIS
About the Role
Medica is hiring a Supervisor, Clinical Quality Review to lead day-to-day clinical review operations supporting regulatory audits and quality initiatives. The role involves supervising Clinical Quality Review RNs, managing workloads, and ensuring audit deliverables.
Key Skills for This Role
Clinical ReviewRegulatory ComplianceHEDISSTARSRADVICD 10
Responsibilities
- Assist Manager with supporting an efficient department operation and workflow
- Ensure workflow is efficient and effective; work with other departments to meet project/audit needs
- Coach staff through complex, ambiguous, or high risk audit scenarios
- Identify and assist in resolution of escalated and/or complex issues
- Support daily operations and long range planning for the department
- Collaborate with departments to ensure consistent and effective communication
- Assist with data collection and audits
- Develop and/or assist with training and training materials
- Work with HR to recruit and hire new staff
- Conduct 1:1 meetings with direct reports, providing feedback, coaching, and performance management
Requirements
- Bachelor's degree or equivalent experience in a related field (Nursing preferred)
- 5 years of relevant clinical healthcare experience beyond degree
- Active Registered Nurse (RN) License preferred
- Minimum 2 years of prior Lead, Supervisor, or Clinical Leadership experience
- Minimum 2 years of experience in a managed care organization supporting quality improvement or clinical review
- Demonstrated experience managing clinical review, quality, or audit work under strict regulatory timelines
- Knowledge of HEDIS, STARS, CMS Cost Audits, RADV, and Clinical Data Validation
- Knowledge of ICD 10 and CPT coding
- Experience leading teams through frequent change
- Effective project management skills
Full Job Posting
About Medica
- Medica is a nonprofit health plan with more than a million members serving communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond.
- We deliver personalized health care experiences and partner closely with providers.
Role Summary
- 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.
Key Accountabilities
- 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.
- 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 departments to ensure consistent, effective and timely communication.
- 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.
- Conduct 1:1 meetings with direct reports, providing timely feedback, coaching, training, mentoring and performance management.
- Monitors and adjusts team workloads as needed to complete projects/audits.
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.
- Active Registered Nurse (RN) License preferred.
- 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.
- Demonstrated experience managing clinical review, quality, or audit work under strict regulatory timelines.
- Knowledge of HEDIS, STARS, CMS Cost Audits, RADV, and Clinical Data Validation.
- Knowledge of ICD 10 and CPT coding.
- Experience leading teams through frequent change and evolving requirements.
- Effective project management skills.
Salary and Benefits
- The full salary grade is $78,700 $134,900 per year.
- Typical hiring salary range is $78,700 $118,020 per year.
- Medica offers competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits.
Workplace Type
- This position is an Office role, which requires an employee to work onsite, on average, 3 days per week.
- Open to candidates near Minnetonka, MN, Madison, WI, Omaha, NE, or St. Louis, MO.
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