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w3r Consulting · 3 hours ago

RN Quality Review Analyst (Medicare / CMS / NCQA)

United States

Contract

Remote

Mid Level

3+ years exp

w3r Consulting is seeking a Quality Review Specialist (RN) to investigate and review quality-of-care grievances ensuring compliance with CMS, NCQA, and state regulations. This role involves evaluating clinical cases, supporting quality improvement initiatives, and collaborating with medical leadership to resolve care issues.

AnalyticsConsultingInformation TechnologyLegal

Diversity & Inclusion

Hiring Manager

Pooja Kumari

Responsibilities

Review and investigate quality-of-care cases (adverse events, critical incidents, never events)

Conduct concurrent and retrospective clinical reviews

Analyze medical records and determine grievance outcomes and severity levels

Collaborate with Medical Directors, Physicians, and QOC leadership

Develop and support corrective action plans

Prepare case summaries, reports, and resolution letters

Ensure compliance with CMS, NCQA, and accreditation standards

Participate in inter-rater reliability and quality reporting activities

Qualification

Registered Nurse (RN) licenseQuality review experienceMedicare/Medicaid knowledgeMicrosoft Office proficiencyAnalytical skillsQuality improvement experienceClinical review experienceCMS knowledgeNCQA knowledgeHEDIS experienceCAHPS experienceHOS experienceDocumentation skillsCommunication skillsAttention to detailIndependent work ability