Note: The job is a remote job and is open to candidates in USA. Medica is a nonprofit health plan serving communities in Minnesota, Nebraska, Wisconsin, and Missouri. The Supervisor, Clinical Quality Review is responsible for leading clinical review operations, ensuring compliance with regulatory standards, and providing support and coaching to the Clinical Quality Review RNs.
Responsibilities
- 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 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
- 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
- Balances productivity expectations with quality and compliance standards
- Support, follow and ensure 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
- Conduct 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
- Encourage staff to identify potential areas for improvement and work efficiencies, identify streamlining opportunities and work 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
- Monitors 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
- Ensure that 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
- Oversee & assist 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
- Translates regulatory and coding requirements into practical guidance for internal teams and external partners
- 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
Skills
- 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
- Candidates without an RN license must possess relevant clinical licensure or credentials appropriate to their healthcare discipline and demonstrate equivalent clinical competency
- 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
- 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 STARS, Off‑Season Data Collection, CMS Cost Audits, RADV and Clinical Data Validation
- Knowledge of ICD‑10 and CPT coding
- 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
- 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)
- 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
- Competitive medical, dental, vision, PTO, Holidays
- Paid volunteer time off
- 401K contributions
- Caregiver services
- Many other benefits to support our employees
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