Remote Utilization Review Rn Jobs in Alton, IL (NOW HIRING)

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for.

We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration — because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued.

The Supervisor, Quality Reviewers is responsible for leading day-to-day clinical review and medical record operations supporting complex, time-sensitive regulatory audits and quality initiatives. This role provides direct supervision, coaching, and workload management for Clinical Quality Review RNs while ensuring audit deliverables, documentation standards, and regulatory timelines are met.

The Supervisor is expected to exercise independent judgment, proactively identify operational risks, resolve escalations, and adapt workflows in response to changing audit requirements, data availability, and business priorities. Performs other duties as assigned.

Successful candidates are organized, adaptable leaders who are comfortable making decisions with incomplete information, managing competing priorities, and supporting staff through complex regulatory work. 

Key Accountabilities

• Assist Manager with supporting an efficient department operation and workflow
  • Ensures workflow is efficient and effective
  • Works with other departments to assure workflow is adequate to meet the needs of the project/audit
  • Coaches staff through complex, ambiguous, or high-risk audit scenarios
  • Identifies and assists in resolution of escalated and/or complex issues
  • Supports daily operations and long-range planning for the department
  • Collaborates with department and all business segments to ensure that consistent, effective and timely communication occurs
  • Assists with data collection and audits
  • Develops and/or assist with training and training materials
  • Work with HR to recruit and hire new staff
  • Supports staff resilience and performance during peak audit periods
  • Balances productivity expectations with quality and compliance standards
  • Support, follow and ensure full compliance with Medica-wide policies and procedures including (but not limited to) all human resources policies, Medica's business expense policies, privacy, and compliance policies

• Supports area staff through team education and 1:1 support

  • Conduct 1:1 meetings with direct reports, providing timely feedback, coaching, training, mentoring and performance management
  • Communicates accurate and timely information to team members to enhance effectiveness and efficiency of performance
  • Encourage staff to identify potential areas for improvement and work efficiencies, identify streamlining opportunities and work with leads and other departments for implementation of improvement opportunities
  • Provides ongoing coaching and development for new and existing team members on a regular basis
  • Monitors and adjusts team workloads as needed to complete projects/audits
  • Create a positive work environment, motivating achievement, minimizing non-productive and restrictive rules, set high standards and recognize and reward good work

• Participates in key work projects to design, review, and support Medica’s quality initiatives and regulatory and accreditation requirements and audits
  • Partners with Manager, Program Manager and Project Leads to design and implement audit workflows
  • Oversees clinical review readiness for audits including documentation standards, reviewer training, and tool readiness
  • Ensures SOPs and job aids are audit ready, defensible, and operationally usable
  • Ensure that quality improvement programs reflect medical policy guidelines, regulatory and accreditation requirements, HEDIS & STAR measurements, RADV, correct coding and Medica’s priorities
  • Reviews tools and Job Aids to assure usability by staff and assures the tool/aid will meet the need of the project/audit
  • Oversee & assist with medical record retrieval work including remote electronic health record (EHR) access and training clinical review team

• Responsible for leading the team in education to business segments/clinics/ providers/other inter-departments regarding Medica quality programs and coding practices
  • Leads the design of educational aides to support Providers and improve compliance.
  • Translates regulatory and coding requirements into practical guidance for internal teams and external partners
  • Serves as a clinical subject matter resource during internal, vendor, or provider discussions
  • Assists Director and Manager as needed to develop, introduce and support overall goals
  • Develops linkages with specific departments on behalf of the Clinical Review area such as Data Management, Legal, Network Management, Compliance, Pharmacy and Complementary Networks.
  • Communicates information to direct reports on Medica’s goals, progress, and next steps.

Required Qualifications

• Bachelor's degree or equivalent experience in a related field (Nursing preferred)
• 5 years of relevant clinical healthcare experience beyond degree, including broad-based clinical practice or equivalent clinical review experience

Skills and Abilities

• Clinical Experience
  • Active Registered Nurse (RN) License preferred
  • Candidates without an RN license must possess relevant clinical licensure or credentials appropriate to their healthcare discipline and demonstrate equivalent clinical competency 
• Leadership & Professional Experience
  • Minimum 2 years of prior Lead, Supervisor, or Clinical Leadership experience
  • 4 years of broad-based nursing or clinical experience, or an equivalent depth of experience within a clinically focused healthcare discipline 
  • Minimum 2 years of experience in a managed care organization, preferably supporting quality improvement, clinical review, or regulatory audit activities

•  Regulatory, Audit, and Clinical Review Expertise
  • Demonstrated experience managing clinical review, quality, or audit work under strict regulatory timelines
  • Demonstrated experience and knowledge of regulatory medical record documentation requirements, including:
    • HEDIS and STARS
    • OffSeason Data Collection
    • CMS Cost Audits
    • RADV and Clinical Data Validation
  • Knowledge of ICD10 and CPT coding

•   Operational Leadership & Decision-Making
  • Experience leading teams through frequent change and evolving requirements
  • Ability to make independent operational decisions in fastpaced, highly regulated environments
  • Demonstrated ability to balance quality, compliance, and productivity expectations

• Data, Technology & Project Management Skills
  
  • Demonstrated effective project management skills, including:
    • Use of planning and tracking tools
    • Development of achievable goals, timelines, and deliverables
    • Innovative and efficient use of resources
  • Advanced computer skills, including Adobe Acrobat and Microsoft 365 applications (Word, Outlook, PowerPoint, Excel, Teams, SharePoint)

• Communication, Team Leadership & Core Competencies
  • 3–5 years of experience communicating effectively with staff and leaders
  • Proven teambuilding, coaching, and mentoring skills
  • Excellent customer service, professionalism, and interpersonal communication abilities
  • High degree of initiative with the ability to work independently and collaboratively
  • Strong problemsolving and critical thinking skills
  • Demonstrated ability to plan, organize, prioritize, and adapt work in response to changing priorities

This position is an Office role, which requires an employee to work onsite, on average, 3 days per week. We are open to candidates located near one of the following office locations: Minnetonka, MN, Madison, WI, Omaha, NE, or St. Louis, MO.

The full salary grade for this position is $78,700 - $134,900. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $78,700 - $118,020. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to compensation, Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.

The compensation and benefits information is provided as of the date of this posting. Medica’s compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.

Eligibility to work in the US: Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States.

We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.