Healthmap Solutions is looking for a RN Quality Assurance Reviewer - Bilingual to join our team. You will be responsible for quality reviews for the Clinical Services and Provider Relations teams, supporting Quality Improvement Programs related to delegation, accreditation, and regulatory standards. As a champion for better health, we are a diverse, growing company committed to our clients and our employees.
What You'll Do
- Audit clinical documentation and calls to ensure NCQA, URAC, and client delegation requirements are met
- Ensure files comply with federal, state, local, and CMS accreditation standards
- Support clinical operations in pre-delegation, delegation, and accreditation reviews
- Audit clinical documentation and member-facing calls as part of clinical excellence initiatives
- Maintain all required quality, organization, and project documentation
- Prepare and audit files based on regulatory, accreditation, and client requirements to provide stakeholders a chance to correct deficiencies
- Prepare and deliver weekly reporting statistics of audit activities and outcomes
- Assist with health plan interface and participate in preparation for external audits
- Act as a subject matter expert providing innovative solutions to problems
- Navigate technical applications including Excel, Outlook, PowerPoint, and Word
- Participate in quality testing of platform and product enhancements for our electronic medical records system
- Perform other duties as assigned
What We're Looking For
- Must be bilingual in English and Spanish
- RN or LPN licensure and a Bachelor’s degree required (8+ years of clinical quality improvement experience considered in lieu of degree/licensure)
- Three (3) years of healthcare experience in a care management or quality management setting
- Experience working in electronic medical records, generating reports, and analyzing data
Nice to Have
- Knowledge of regulatory, CMS, and accreditation agencies like NCQA and/or URAC
- Knowledge of Care Management and Managed Care settings
- Experience monitoring calls of a clinical staff
Technical Stack
- Microsoft Office: Outlook, Word, Excel, PowerPoint
- Electronic medical records systems
Team & Environment
You will work in conjunction with the Quality Manager and collaborate with the Clinical Services, Provider Relations, and Clinical Training teams.
Work Mode
This is a 100% remote position.
As an Equal Opportunity Employer, we will not discriminate against any job candidate or employee due to age, race, religion, ethnicity, national origin, gender, gender identity/expression, sexual orientation, disability, familial status, veteran status, marital status, parental status, or pregnancy. In our innovative and inclusive workplace, we prohibit discrimination and harassment of any kind.
