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

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