Registered Nurse, Medicare Quality Assurance Reviewer

Clover Health

Registered Nurse (RN) reviewing Medicare Quality Assurance at Clover Health. Supporting evidence-based decision-making with the utilization management team for members' care.

Posted 6/23/2026full-timeRemote • 🇺🇸 United StatesMid-LevelSenior💰 $92,000 - $120,000 per yearWebsite

About the role

Key responsibilities & impact

Provide clinical expertise support for Clover vendors and Medical Directors.
Create and assign inter-rater reliability reviews to RN reviewers and Medical Directors.
Complete monthly MD Quality Assurance (QA) reviews to ensure clinical compliance with Medicare regulations.
Service line clinical reviews.
Clinical Medical Record Review Subject Matter Expert (SME).
Identifying clinical opportunities for improvement and communicating to upper management.
Tracking clinical performance and evaluation of vendors medical reviewers.
Clinical support for new medical review process implementations.
Monitor and track CMS Medicare clinical updates that impact Clover clinical processes, partner with management to implement clinical changes.
Displays Flexibility to adjust work based on new challenges or feedback.
Clinical collaboration with cross-functional departments.

Requirements

What you’ll need

You have an active and valid RN license; required.
You have a minimum of 3 years of Medicare Utilization Management medical necessity review experience; required.
You have a strong knowledge of applying CMS guidelines, and NCD-LCD to Medicare medical necessity reviews; required.
You have experience working in a Medicare Advantage plan; preferred.
You have Quality Assurance experience; required.
You have RN clinical experience in a hospital setting; preferred.
You have previous experience in leading vendor relationships and building clinical review teams.
You have excellent interpersonal skills and ability to communicate with patients and colleagues.
You have experience working remotely; preferred.

Benefits

Comp & perks

Financial Well-Being: Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities. Additionally, we offer a performance-based bonus program, 401k matching, and regular compensation reviews to recognize and reward exceptional contributions.
Physical Well-Being: We prioritize the health and well-being of our employees and their families by providing comprehensive medical, dental, and vision coverage. Your health matters to us, and we invest in ensuring you have access to quality healthcare.
Mental Well-Being: We understand the importance of mental health in fostering productivity and maintaining work-life balance. To support this, we offer initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy. Additionally, we embrace a remote-first culture that supports collaboration and flexibility, allowing our team members to thrive from any location.
Professional Development: Developing internal talent is a priority for Clover. We offer learning programs, mentorship, professional development funding, and regular performance feedback and reviews.
Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities
Reimbursement for office setup expenses
Monthly cell phone & internet stipend
Remote-first culture, enabling collaboration with global teams
Paid parental leave for all new parents
And much more!

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

Medicare Utilization Managementmedical necessity reviewQuality Assuranceclinical record reviewCMS guidelinesNCD-LCDclinical complianceclinical performance trackingclinical process implementationvendor relationship management

Soft Skills

interpersonal skillscommunicationflexibilitycollaborationleadership

Certifications

RN license