Remote Clinical Quality Review Nurse & Coder

Medica; Minnetonka (MN); Remote; USD 70,000 - 120,000; Full time

Job summary

Medica, a nonprofit health plan, seeks a Clinical Quality Review III (RN and Certified Coder) to conduct medical record reviews, data collection, and clinical audits across its network. You will assess documentation accuracy, adherence to clinical standards, and compliance with HEDIS, STARS, CMS Cost Audit, and RADV, while sharing expertise to strengthen quality review processes.

This remote role requires strong nursing and coding skills, 5+ years in quality reviews, and the ability to educate

Qualifications

• RN license required.
• 5+ years of clinical quality chart reviews, data analysis, auditing or quality improvement.
• Current Coding Certification (CCA, CPC, CPC-P, CPC-H, CCS, CCS-P, RHIT, RHIA) or ability to obtain CPC or CRC within 1 year.

Responsibilities

• Conduct medical record reviews and clinical quality audits to verify compliance with program rules.
• Perform data abstraction and verification for required quality measures.
• Collaborate with internal partners to clarify clinical requirements and documentation needs.
• Provide education and feedback to providers regarding documentation expectations and audit results.
• Support corrective action plans and continuous improvement of quality processes.

Skills

Nursing

Data analysis

Medical record review

Auditing

Quality improvement

Regulatory knowledge

Communication skills

Education

Nursing degree

Tools

Adobe Acrobat

MS Office

SharePoint

Job description

Medica, a nonprofit health plan, seeks a Clinical Quality Review III (RN and Certified Coder) to conduct medical record reviews, data collection, and clinical audits across its network. You will assess documentation accuracy, adherence to clinical standards, and compliance with HEDIS, STARS, CMS Cost Audit, and RADV, while sharing expertise to strengthen quality review processes.

This remote role requires strong nursing and coding skills, 5+ years in quality reviews, and the ability to educate