RN Quality Analyst — Remote, Medicaid & AI Audits

Acentra Health; McLean (VA); À distance; USD 74 000 - 92 000; Plein temps

Avantages offerts par ce poste

Health benefits

Paid time off

Retirement plan

Wellness program

Educational assistance

Employee discounts

Résumé du poste

Acentra Health is seeking a Nurse Quality Analyst to join our growing team. The analyst supports the Integrated Health Solutions division by evaluating the quality, accuracy, consistency, and timeliness of utilization management reviews across Medicaid programs.

This role performs structured quality audits of clinical reviews, including reviews supported by artificial intelligence, validates alignment with clinical criteria and contract requirements, identifies trends and improvement

Qualifications

• Active, unrestricted RN license required.
• State-approved nursing education program completed (certificate, diploma, associate, or bachelor’s preferred).
• 3+ years of clinical nursing, UM, quality, or related healthcare experience with quality audits.
• Extensive Medicaid experience.
• Experience reviewing prior authorization, concurrent, retrospective, or other UM cases using clinical criteria.

Responsabilités

• Plan, develop, implement, and monitor internal QA and improvement programs for consistent utilization management operations.
• Perform prospective, concurrent, retrospective, and focused quality audits of Medicaid UM reviews, including AI-supported efforts.
• Evaluate clinical review accuracy, completeness, timeliness, and compliance with criteria, policies, and contract requirements.
• Validate AI-assisted outputs against documentation and criteria for accuracy and consistency.
• Develop standardized audit tools and methodologies; monitor inter-rater reliability and other quality measures.

Connaissances

RN license

Quality audits

Medicaid experience

AI-assisted reviews

Microsoft Office

Formation

Nursing degree (RN)

Outils

IQC databases

Quality tools

Description du poste

Acentra Health is seeking a Nurse Quality Analyst to join our growing team. The analyst supports the Integrated Health Solutions division by evaluating the quality, accuracy, consistency, and timeliness of utilization management reviews across Medicaid programs.

This role performs structured quality audits of clinical reviews, including reviews supported by artificial intelligence, validates alignment with clinical criteria and contract requirements, identifies trends and improvement