Clinical Quality Review Nurse

About the role

The Clinical Quality Review Nurse supports the Clinical Quality and Record Review team by conducting in‑depth post‑service clinical reviews across all care settings. The role ensures that potential quality issues are identified, investigated, and resolved in line with TRICARE and plan requirements, ultimately improving clinical service delivery.

Key responsibilities

• Perform retrospective clinical case reviews to detect deviations from standard of care and identify gaps.
• Document investigation progress and findings in internal databases or Excel spreadsheets.
• Conduct literature reviews, abstract relevant data, and summarize findings.
• Contact providers or facilities to obtain additional medical records as needed.
• Execute chart reviews and audits both electronically and on‑site.
• Write concise investigative summaries and quality review determination letters.
• Collaborate with internal and external stakeholders, including vendors.
• Maintain strict confidentiality of all medical records and related documents.
• Participate in data collection, analysis, and reporting for quality reports and committees.
• Engage in continuous quality improvement and root‑cause analysis activities.

Required profile

• Minimum five years of healthcare quality management experience.
• Minimum five years of clinical nursing experience.
• Experience in quality assurance/improvement within a managed health plan, integrated health system, or regulatory agency.

Required skills

• Proficiency with Excel for data abstraction and reporting.
• Intermediate statistical analysis and data interpretation.
• Ability to abstract and analyze medical records and clinical data.
• Project management capabilities.