Clinical Quality Nurse - 252102 Job at Medix™, Manhattan, KS

d0RaYnUyRmdKMVg1ZG9ISzIzWG5mT2oyQ3c9PQ==
  • Medix™
  • Manhattan, KS

Job Description

Clinical Quality Review Specialist (LPN/RN)

Position Overview

We are seeking a detail-oriented Clinical Quality Review Specialist to support the identification, investigation, and resolution of clinical quality issues across all care settings. This role works both independently and collaboratively with internal teams and external vendors to ensure alignment with health plan standards and regulatory requirements.

The ideal candidate brings a strong clinical background, analytical mindset, and a passion for improving quality of care and service delivery.

Key Responsibilities

  • Conduct comprehensive post-service clinical reviews across multiple care settings
  • Review, track, and investigate potential clinical quality issues in accordance with plan requirements
  • Analyze medical records and clinical data to identify trends, gaps in care, and deviations from standards
  • Recommend corrective actions and support implementation of quality improvement initiatives
  • Collaborate with cross-functional teams and external partners to ensure timely resolution of cases
  • Manage an assigned caseload while meeting established productivity and performance metrics

Required Qualifications

  • Active LPN/LVN or RN license in New Jersey or New York
  • Strong ability to review, abstract, and analyze medical records and clinical data
  • In-depth knowledge of medical terminology, anatomy, physiology, and disease processes
  • Working knowledge of ICD-10, CPT, and HCPCS coding
  • Familiarity with Medicare, Medicaid, and/or TRICARE guidelines
  • Proven ability to identify clinical quality issues and recommend appropriate solutions
  • Excellent communication skills, both written and verbal
  • Strong organizational and time management skills with the ability to work independently
  • Intermediate data analysis and interpretation skills
  • Proficiency in Microsoft Office (Excel, Outlook, PowerPoint, Word); experience with Access or Visio is a plus
  • Strong customer service mindset

Preferred Qualifications

  • Prior experience working within a health plan environment

Schedule

  • Monday – Friday, 9:00 AM – 5:00 PM
  • Hybrid schedule:
  • Remote: Monday & Friday
  • In-office (required): Tuesday, Wednesday, Thursday

Why Join Us?

  • Full benefits upon permanent hire
  • Collaborative, close-knit team environment
  • Strong opportunity for career growth and advancement

Job Tags

Permanent employment, Work at office, Remote work, Monday to Friday

Similar Jobs

The GSI Family of Companies

Construction Estimator - Federal contract position - Not remote Job at The GSI Family of Companies

 ...Cost Estimator (Construction) to join our team supporting our Federal client! In this role you will join a multi-disciplined program...  ...and provide review and analysis of multiple construction contractors RFIs Utilize training in the prescribed estimating software... 

Servicon Systems, Inc.

Cleaner Job at Servicon Systems, Inc.

 ...Janitorial/Custodial LAC Courts - Compton Who We Are We are a family and women-owned local company with over 50 years of experience in environmental solutions, specializing in infection prevention for complex facilities. Our responsiveness allows us to quickly... 

Freedom Academy Inc

Junior High History Teacher - Small Charter School Job at Freedom Academy Inc

: We are looking for an educator who can make history engaging, relevant, and meaningful for students in Junior High. The ideal candidate will inspire curiosity about the past while helping students develop critical thinking, analysis, and discussion skills. Responsibilities...

Cube Hub Inc.

Bilingual Customer Support Representative (Spanish/English) Job at Cube Hub Inc.

 ...Job Title: Bilingual Customer Support Representative (Spanish/English) Technical Support Location: Johnston, IA Duration: 24+ Months (Contract/Temp with the possibility of extension) Shift: 1st Shift Pay Range: $20.50/hr Job Description: We are seeking... 

Confidential

PT ESL Teacher for Kindergarten Job at Confidential

PT ESL teacher for a kindergarten, Job Contents: 1) Prepare the lesson plan and content in prior to the lessons. 2) Give out the lessons according to the schedule. Job requirements: 1Bachelor above degree 2Certificate TEFL, TESOL or CELTA Location: Shanghai...