Clinical Review Nurse, Health Plans

Orlando FL 32812

Job Description

Assists with the development of improvement projects for the health plan. Reviews documentation and interprets data obtained from clinical records required for the HEDIS project. Develops and implements interventions needed to improve quality scores and meet state, federal and accreditation requirements at the Health Plan. Assists with the resolution of potential quality of care issues.

● Develops and implements Performance Improvement Projects (PIPs) and Plan Do Study Act (PDSA) cycles per state contractual requirements.
● Implements member and provider interventions for the health plan to improve compliance for PIPs, PDSAs, HEDIS, CAHPS and any other quality measures needed to meet state, federal, contractual and accreditation requirements. 
● Monitors health plan’s interventions implemented as part of the PIPs and PDSAs and adjusts based on results to meet the state contractual requirements. 
● Collaborates with the HEDIS team to perform chart reviews and abstractions as needed to meet HEDIS timelines and deliverables.
● Provides reports and analysis for monthly/quarterly trending and presents to the plan’s Quality committee to obtain input, recommendations and approval. 
● Develops and implements Potential Quality Issue (PQI) process. 
● Reviews sentinel events and member concerns reported for potential quality of care issues. 
● Assists with the development of data collection tools needed to monitor PIP and PDSA interventions.
● Prepares and presents results that include analysis and trending to plan leadership. 
● Maintains documentation in accordance with contractual requirements. 
● Conducts chart review to determine if a potential quality issue has occurred. 
● Provides feedback as needed for any potential quality issues. 
● Implements corrective action plans as needed per policy guidelines. 
● Conducts analysis, both quarterly and annually, on the Plan’s efforts to improve quality measure performance. 
● Completes annual medical record review activities, including HEDIS and Clinical Practice Guidelines development and review. 
● Performs other duties and projects as assigned. 

General Job Information


Clinical Review Nurse, Health Plans



Job Family

Quality Group


United States of America

FLSA Status

United States of America (Exempt)

Recruiting Start Date


Date Requisition Created


Minimum Qualifications


Bachelors: Healthcare (Required), Bachelors: Nursing (Required)

License and Certifications - Required

RN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt

License and Certifications - Preferred

Other Job Requirements


● Master’s degree in related discipline or equivalent work experience 
● Demonstrated experience in leading significant cross-functional work 
● Excellent knowledge of HEDIS, NCQA, Medicare Stars and Medicaid 
● Conceptual and in-depth knowledge of the healthcare industry 
● Ability to manage relationships with an emphasis on internal and external mid-level relationships 
● Ability to work across all levels of the organization, including working with executive audiences, vendors and the government as a customer 
● Demonstrated ability to select and implement strategies that are most likely to be successful 
● Minimum five years experience in managed care 
● Internal audit experience ● Registered Nurse, or appropriate clinical licensure 
● Bachelor’s degree in healthcare or related discipline 
● Five plus years of experience in quality management 
● Demonstrated understanding of healthcare industry standards, HEDIS and NCQA 
● Proficient in Microsoft Office tools 
● Strong analytical skills and strategic thinking 
● Strong communication skills, both verbally and written 
● Ability to interact effectively with business owners, senior management, and peers across the organization 

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled

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