Clinical QA Nurse Specialist

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.