Clinical QA Nurse Specialist

Vida is looking for a licensed RN or LPN to manage clinical review requests, escalations, and member inquiries in a fully remote, virtual care setting. You’ll analyze medical records, investigate concerns from members and internal teams, and see each case through to resolution. Along the way, you’ll help shape quality, safety, and process improvements across our clinical operations.

Responsibilities:

• Intake, triage, track, and respond to clinical review requests, escalations, and inquiries in accordance with established service level agreements (SLAs).
• Review and analyze patient medical records, extracting relevant clinical information for presentation to providers and leadership as needed.
• Investigate and address clinical escalations originating from members, Member Support, Account Management, Clinical Operations, and other internal stakeholders.
• Respond to member inquiries professionally, compassionately, and in accordance with Vida clinical guidelines and program requirements.
• Collaborate closely with Providers, Clinical Assistants, and cross-functional teams to support continuity of care and efficient resolution of member concerns.
• Monitor cases through resolution and ensure timely follow-up and documentation.
• Support quality assurance initiatives by identifying trends, process improvement opportunities, and potential member safety concerns.
• Assist with provider performance monitoring, quality reviews, and operational audits as assigned.
• Maintain accurate, complete, and timely documentation within all required systems.
• Utilize provider messaging platforms, templates, workflows, and telehealth technologies efficiently and appropriately.
• Perform all duties within the scope of practice and in accordance with Vida clinical guidelines.
• Additional responsibilities as needed.

Qualifications:

• Active RN or LPN license in good standing.
• Minimum of 2 years of experience in a primary care, family medicine, internal medicine, or outpatient clinical setting.
• Experience reviewing medical records and clinical documentation.
• Strong written and verbal communication skills.
• Excellent organizational skills and attention to detail.
• Proven ability to analyze situations, identify issues, and implement appropriate solutions.
• Ability to work independently and effectively in a fully remote environment.
• Strong computer and technology proficiency.
• Able to efficiently utilize cloud-based technologies including Slack, Google Workspace, Zendesk, Zoom, electronic medical records, and telehealth platforms.
• Able to navigate multiple systems simultaneously while maintaining accuracy and efficiency.
• Demonstrated ability to manage multiple priorities in a fast-paced setting.
• Commitment to providing compassionate, patient-centered support.
• Able to adapt to evolving workflows, technology platforms, and operational processes.

Preferred:

• Experience in a telehealth or virtual care environment.
• Experience with utilization management, prior authorizations, or clinical review processes.
• Experience supporting obesity medicine, chronic disease management, primary care, or population health programs.
• Experience with quality assurance, compliance, clinical operations, or care coordination activities.
• Familiarity with electronic prescribing systems and electronic medical records.

Originally posted on Himalayas