Market Clinical Quality Specialist II

CareSource

. Complete assigned case/file reviews to ensure adherence to regulatory requirements and Standard Operating Procedures (SOPs) .

Posted 9/23/2026full-timeRemote • United StatesJunior💰 $72,200 - $115,500 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Quality Improvement, Case Management, and Utilization Review, with a strong focus on regulatory compliance and training development. Proficient in project management and effective communication across interdisciplinary teams.

Highest-signal resume keywords

Registered Nurse (RN) LicensureQuality Improvement ExperienceCase Management Certification (CCM)Intermediate Proficiency in Microsoft ExcelKnowledge of Medicaid and Medicare

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Quality ImprovementProject ManagementCase ManagementUtilization ReviewTechnical Writing

Soft Skills

Strong Written and Verbal CommunicationEffective Problem-SolvingAttention to DetailInterpersonal SkillsEffective Listening

Tools & Technologies

Microsoft ExcelMicrosoft AccessMicrosoft WordSharePointPowerPoint

Certifications & Qualifications

Registered Nurse (RN) LicensureCase Management Certification (CCM)

Industry Keywords

Regulatory RequirementsStandard Operating Procedures (SOPs)Corporate Integrity AgreementHealthcare FieldAccreditation

About the role

Key responsibilities & impact

Complete assigned case/file reviews to ensure adherence to regulatory requirements and Standard Operating Procedures (SOPs)
Conduct monthly inter-rater reliability monitoring of case reviews
Identify training and development opportunities and collaborate with peers and Care Management to develop education and training
Assist Management with reporting case reviews at aggregate and individual contributor levels
Serve as a subject matter expert in assigned areas
Participate in interdepartmental meetings and workgroups regarding Care Management procedures
Provide cross-functional assistance for monitoring, accreditation and operational responsibilities
Maintain familiarity with applicable Federal and State Requirements, including Corporate Integrity Agreement responsibilities
Monitor regulatory changes, identify impacted areas, communicate changes and assist with implementation
Pursue best practices and improvement opportunities for health services monitoring and accreditation
Facilitate implementation of improvement initiatives
Perform other job-related instructions as requested

Requirements

What you’ll need

Associate of Science in Nursing (ASN) is required
One to three (1 to 3) years of experience in Quality Improvement, Project Management, Case Management or Utilization Review is required
Current, unrestricted Registered Nurse (RN) licensure in state of practice is required
Bachelor of Science in Nursing (BSN) is preferred
Minimum of three (3) years of diverse clinical experience as an RN is preferred
Intermediate proficiency in Microsoft Excel, Access and Word
Intermediate skill level with SharePoint
PowerPoint and Visio preferred
Strong written and verbal communication skills
Ability to work independently and within a team environment
Familiarity with the healthcare field
Knowledge of Medicaid and Medicare
Effective listening and critical thinking skills
Strong interpersonal skills and high level of professionalism
Effective problem-solving skills with attention to detail
Ability to develop, prioritize and accomplish goals
Technical writing skills
Ability to coordinate complex projects and multiple meetings
Ability to work with a variety of disciplines and levels of staff across departments
Case Management Certification, such as Certified Case Manager (CCM), is highly preferred

Benefits

Comp & perks

Bonus tied to company and individual performance may be available
Comprehensive total rewards package
Employee total well-being support