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Supervisor, Clinical Quality Review
Medica
Madison, UAE
Full Time
Manager
Hybrid
3 weeks ago
Clinical ReviewRegulatory ComplianceHEDISSTARSCMS Cost AuditsRADV
Free
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Clinical ReviewRegulatory ComplianceHEDIS
About the Role
Medica is hiring a Supervisor, Clinical Quality Review to lead clinical review and medical record operations for regulatory audits. The role supervises Clinical Quality Review RNs, manages workflows, and ensures compliance with HEDIS, STARS, and CMS requirements.
Key Skills for This Role
Clinical ReviewRegulatory ComplianceHEDISSTARSCMS Cost AuditsRADV
Responsibilities
- Lead day to day clinical review and medical record operations for regulatory audits
- Provide direct supervision, coaching, and workload management for Clinical Quality Review RNs
- Ensure audit deliverables, documentation standards, and regulatory timelines are met
- Proactively identify operational risks, resolve escalations, and adapt workflows
- Conduct 1:1 meetings with direct reports, providing feedback and performance management
- Oversee clinical review readiness for audits including documentation standards and training
- Design and implement audit workflows in partnership with Manager and Project Leads
- Lead team education to business segments regarding quality programs and coding practices
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 regulatory audit
- Experience managing clinical review under strict regulatory timelines
- Knowledge of HEDIS, STARS, CMS Cost Audits, RADV, and ICD 10/CPT coding
- Advanced computer skills including Adobe Acrobat and Microsoft 365
Full Job Posting
Position Overview
- 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.
Key Accountabilities
- Assist Manager with supporting efficient department operation and workflow.
- Support area staff through team education and 1:1 support.
- Participate in key work projects to design, review, and support quality initiatives and regulatory audits.
- Lead team education to business segments regarding quality programs and coding practices.
Required Qualifications
- 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.
Skills And Abilities
- Clinical Experience with RN license preferred.
- Regulatory, Audit, and Clinical Review Expertise including HEDIS, STARS, CMS Cost Audits, RADV.
- Knowledge of ICD 10 and CPT coding.
- Operational Leadership & Decision Making.
- Data, Technology & Project Management Skills.
- Communication, Team Leadership & Core Competencies.
Salary and Benefits
- Salary range: $78,700 $134,900; typical hiring range $78,700 $118,020.
- Benefits include medical, dental, vision, PTO, holidays, paid volunteer time off, 401K contributions, caregiver services.
Workplace
- Office role requiring onsite work on average 3 days per week.
- Open to candidates near Minnetonka, MN; Madison, WI; Omaha, NE; or St. Louis, MO.
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