[Hiring] Registered Nurse (RN) Medicare Quality Assurance Reviewer @Clover Health

Role Description

As a Registered Nurse (RN) Medicare Quality Assurance Reviewer, you will:

• Provide clinical expertise support for Clover vendors and Medical Directors.
• Create and assign inter-rater reliability reviews to RN reviewers and Medical Directors.
• Complete monthly MD Quality Assurance (QA) reviews to ensure clinical compliance with Medicare regulations.
• Conduct service line clinical reviews.
• Act as a Clinical Medical Record Review Subject Matter Expert (SME).
• Identify clinical opportunities for improvement and communicate to upper management.
• Track clinical performance and evaluate vendors' medical reviewers.
• Provide clinical support for new medical review process implementations.
• Monitor and track CMS Medicare clinical updates that impact Clover clinical processes, partnering with management to implement clinical changes.
• Display flexibility to adjust work based on new challenges or feedback.
• Collaborate clinically with cross-functional departments.

Success in this role looks like:

• By the end of your first 90 days:
• Build a strong foundation in Clover’s utilization management, quality assurance, and clinical review processes.
• Develop proficiency in Medicare regulations, clinical review requirements, and Clover’s quality standards.
• Establish effective working relationships with internal stakeholders, vendors, and Medical Directors.
• Consistently perform quality assurance reviews with accuracy, sound clinical judgment, and attention to compliance requirements.
• By 6 months:
• Independently manage quality assurance responsibilities across utilization management service lines.
• Serve as a reliable clinical resource for quality, compliance, and review-related questions.
• Contribute to process improvements by identifying opportunities to enhance quality, consistency, and operational effectiveness.
• Partner effectively with vendors, Medical Directors, and cross-functional teams to support quality outcomes and regulatory compliance.
• Future state:
• Be recognized as a trusted clinical quality and utilization management subject matter expert.
• Drive continuous improvement through trend analysis, performance insights, and recommendations that strengthen quality and compliance programs.
• Support the evolution of clinical review processes, technology-enabled solutions, and operational initiatives that improve efficiency and member outcomes.
• Influence organizational success by maintaining high standards of clinical excellence, regulatory compliance, and collaborative partnership across the organization.

Qualifications

• Active and valid RN license; required.
• Minimum of 3 years of Medicare Utilization Management medical necessity review experience; required.
• Strong knowledge of applying CMS guidelines, and NCD-LCD to Medicare medical necessity reviews; required.
• Experience working in a Medicare Advantage plan; preferred.
• Quality Assurance experience; required.
• RN clinical experience in a hospital setting; preferred.
• Previous experience in leading vendor relationships and building clinical review teams.
• Excellent interpersonal skills and ability to communicate with patients and colleagues.
• Experience working remotely; preferred.

Benefits

• Financial Well-Being: Competitive base salary, equity opportunities, performance-based bonus program, 401k matching, and regular compensation reviews.
• Physical Well-Being: Comprehensive medical, dental, and vision coverage.
• Mental Well-Being: No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy.
• Professional Development: Learning programs, mentorship, professional development funding, and regular performance feedback and reviews.
• Additional Perks: Employee Stock Purchase Plan (ESPP), reimbursement for office setup expenses, monthly cell phone & internet stipend, remote-first culture, paid parental leave for all new parents, and much more!