Quality Review Nurse, Clinical Solutions (CCM Required)

U.S. healthcare today is confusing, inefficient and expensive. Maestro Health is on a mission to change that by making health and benefits people-friendly again.

Our team of Maestronites (yep, that’s what we call ourselves) is revolutionizing not only the way we view health and benefits but also the way we shop, enroll and live with our benefits using a tech-meets-service approach. We’re a team that takes our work (but not ourselves) seriously and loves the occasional Seinfeld reference—just Google “the Maestro Seinfeld episode” and you’ll see why we chose our name. 

WHAT YOU WILL BE DOING:

Reporting to the Sr. Director, Clinical Solutions, the Quality Review Nurse, will support the Clinical Solutions department by performing quality reviews of clinical documentation and processes, assist in department training and orientation, manage departmental clinical review requests, and apply knowledge and experience in care and utilization management to identify quality improvement opportunities.

    • Perform quality reviews of clinical documentation and processes to ensure adherence to clinical best practice guidelines, regulatory requirements, and adherence to any accreditation requirements.
    • Assist to incorporate best clinical practice research to devise strategies for quality improvement, wellness, and other medical management approaches that will enhance health outcomes and reduce costs of care for members and clients.
    • Perform clinical review and consults for internal and external stakeholder requests and manage care management and utilization management complex cases as assigned.
    • Monitor utilization measures and identify key trends to highlight population health opportunities and works with department leadership to develop improvement plans to ensure quality services are delivered and to achieve member satisfaction.
    • Assist in the development and deliver clinical process/technology training for the clinical solutions department.
    • Assist in clinical onboarding training and new-hire orientation performance monitoring process.
    • Perform other similar and related duties as required or as directed

    WHAT SUCCESS LOOKS LIKE:

    • Demonstrate ability to work autonomously, establish priorities and accountability to achieve quality clinical outcomes and meet established deadlines.
    • Demonstrate the ability to be flexible and function effectively in a fluid, dynamic, and rapidly changing healthcare environment.
    • Demonstrate leadership qualities and change management strategies to mentor and support the clinical team in achieving quality outcomes and departmental KPIs.
    • Demonstrate expertise in clinical research and manage care concepts, strong interpersonal skills to effectively collaborate with leadership, clients, practitioners, the interdisciplinary healthcare team, community agencies, and members.


    WHAT YOU NEED:

    • REQUIRED: RN Licensure in state of residence and Associate Degree (ADN) in nursing. A Bachelor’s Degree (BSN) in nursing preferred.
    • REQUIRED: Certification in case management. (CCM)
    • REQUIRED: Minimum of (3) three years of experience in clinical leadership and/or training in care/case management and/or utilization management. Quality experience in the managed care setting preferred.
    • Minimum of (5) five years of experience working as a care manager in managed care, health system strategy, population health, accountable care, or a risk-based reimbursement environment.
    • Ability to foster innovation and thought leadership; exemplary written and interpersonal communication skills.
    • Working knowledge of IT systems and healthcare software.
    • Exhibits leadership management qualities that demonstrate the ability to direct significant change activities, foster innovation and develop strategies and improve employee management and fiscal responsibility.
    • Demonstrates team management and training experience, ability to mentor staff to achieve professional growth and success.

    WHY WORK AT MAESTRO HEALTH?

    • Personal, Vacation and Sick Time
    • Medical and Prescription
    • Dental
    • Vision
    • Life and Disability
    • Health and Wellness programs
    • 401k with Employee Match
    • Kashable
    • Figo – Pet Insurance

    We have great perks in each of our offices, along with a fun, energetic and fast-paced environment, and what will really drive you is our vision. Maestro Health is making employee health & benefits people-friendly again by making healthcare easy to understand, tools easy to use, and costs easy to control. We are aiming to become a household name within the employee health & benefits space.

    We can’t do that without great people. We want to hear “WOW! That was the best job and business experience I ever had!” from every Maestronite – past, present, and future. You should be personally challenged, laugh, work your tail off and look forward to coming to work.

    Are you ready to become a Maestronite? Let’s do this.

    Maestro Health is an equal opportunity workplace. We are committed to equal opportunity regardless of race, color, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, or veteran status.