Sr Nurse - Quality & Acc.
Core
Ensures clinical review departmental activities meet regulatory, client contract, and accreditation (URAC/NCQA) standards through quality assurance audits, root cause analysis, and process improvement.
Role type
Senior Nurse - Quality & Accreditation (Clinical Review)
Builds
Quality assurance processes and compliance frameworks for clinical review operations
Domain
Healthcare / Utilization Management / Quality Assurance
Deliverable
dashboards & analysis
Required skills
Clinical nursing (RN), Utilization management, Quality auditing, Root cause analysis, Regulatory compliance (CMS/URAC/NCQA), Data analysis (Excel), HIPAA compliance
Preferred skills
Acute care experience, Quality improvement project leadership
Technologies
Microsoft Office (Excel), Utilization management systems
Responsibilities
Conduct internal and external quality audits (IRR, adverse determinations, physician reviewer audits), analyze audit data for trends and root causes, prepare case files for regulatory/accreditation surveys, implement quality improvement projects, maintain credentialing and compliance logs.
Seniority
Senior, hands-on IC