Quality Review RN

Richmond VA 23233

Job Description

The Quality Review Nurse assists with the resolution of potential quality of care issues. Reviews documentation and interprets data obtained from clinical records to apply appropriate level in line with regulatory and accreditation requirements for potential quality issues. Documents and summarizes for health plan leadership the issues, recommended course of action and the results.

Essential Functions

  • Reviews all sentinel events and member concerns reported for potential quality of care issues.
  • Coordinates reviews with physician advisors and committees as appropriate .
  • Assists with development of process to maintain ongoing assessment and evaluation of provider site complaints, medical record keeping standards, continuity and coordination of care standards and clinical guidelines in support of QI activities, in accordance with NCQA standards, including the approval process, distribution, data collection, analysis and revisions as necessary. 
  • Maintains database to support trending and reporting of adverse outcomes resulting from clinical care provided. 
  • Provides reports and analysis for monthly/quarterly trending and presents to the plan’s Quality committee to obtain input, recommendations and approval. 
  • Assists with the development of data collection tools in accordance with state, federal and accreditation standards. 
  • Conducts chart review to determine if a potential quality issue has occurred.
  • Prepares and presents results that include analysis and trending to plan leadership. 
  • Develops and implements corrective action plans as needed per policy guidelines. 
  • Maintains documentation in accordance with contractual requirements. 
  • Conducts analysis both quarterly and annually on the Plan’s efforts to improve the safety of our members. 
  • 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


Quality Review RN



Job Family

Quality Group


United States of America

FLSA Status

United States of America (Exempt)

Recruiting Start Date


Date Requisition Created


Work Experience



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


Preferred Qualifications

  • 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 

Required Qualifications

  • 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. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.

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