Nurse Quality Analyst (RN)

Job Summary and Responsibilities

Acentra Health is looking for a Nurse Quality Analyst to join our growing team.

Job Summary:

The Nurse Quality Analyst supports the Integrated Health Solutions division by evaluating the quality, accuracy, consistency, and timeliness of utilization management reviews across Medicaid programs. This role performs structured quality audits of clinical reviews, including reviews supported by artificial intelligence, validates alignment with clinical criteria and contract requirements, identifies trends and improvement opportunities, and partners with operational and clinical leaders to strengthen review quality. The analyst also supports quality initiatives and helps train clinical staff on quality processes, audit standards, documentation expectations, and continuous improvement practices.

This position is fully remote within the United States, with a preference for candidates located in the Eastern Time Zone. However, scheduling flexibility is available for candidates in the Central and Mountain Time Zones.

Responsibilities:

Plan, develop, implement, and monitor internal quality assurance and improvement programs to support consistent, efficient, compliant, and member-centered utilization management operations.

Perform prospective, concurrent, retrospective, and focused quality audits of utilization management reviews for Medicaid programs, including reviews supported by artificial intelligence (AI) or other automation tools.

Evaluate clinical review accuracy, completeness, consistency, timeliness, medical necessity rationale, application of clinical criteria, and compliance with applicable state, federal, and contractual requirements.

Validate AI-assisted recommendations and automated outputs against clinical documentation, applicable criteria, and policies to ensure accuracy and consistency with reviewer judgment.

Develop and apply standardized audit tools and quality methodologies to assess nurse and physician reviewer performance, including accuracy, inter-rater reliability, and other quality measures, in collaboration with Operations Management and Medical Directors.

Document and analyze audit findings, identify trends and root causes, provide constructive feedback, and communicate quality concerns and recommendations to clinical staff and operational leadership.

Maintain internal quality control (IQC) databases, audit records, trend reports, action plans, and other required documentation, modifying data collection and reporting processes as necessary to meet contractual requirements.

Prepare recurring and ad hoc quality reports for Integrated Health Solutions leadership and other internal stakeholders, escalating significant risks, patterns, and compliance concerns as appropriate.

Collaborate with operations managers, clinical leaders, medical directors, training teams, and subject matter experts to identify improvement opportunities, implement corrective actions, and monitor their effectiveness.

Identify training needs and coordinate, develop, and deliver education for clinical and DHA staff, including onboarding, refresher training, medical record abstraction, clinical reviews, audit standards, quality measures, clinical criteria, and inter-rater reliability.

Facilitate calibration sessions and targeted coaching to improve clinical review consistency, documentation accuracy, and overall quality performance.

Support departmental workload as needed, including medical record abstraction, clinical case reviews, quality studies, and other assigned clinical or quality activities.

Stay current with Medicaid utilization management practices, regulatory and contractual requirements, quality standards, and responsible use of AI in clinical workflows.

Serve as backup to the Director of Operations as needed.

Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

The list of accountabilities is not intended to be all-inclusive and may be expanded to include other education- and experience-related duties that management may deem necessary from time to time.

Qualifications

Required Qualifications

Active, unrestricted Registered Nurse (RN) license

Completion of a state-approved nursing education program resulting in a certificate, diploma, associate degree, (bachelor’s preferred), in accordance with applicable state licensure requirements

3+ years of clinical nursing, utilization management, quality, or related healthcare experience, with demonstrated experience performing or overseeing quality audits
Extensive experience with Medicaid programs
Experience reviewing prior authorization, concurrent review, retrospective review, medical necessity, or other UM cases using established clinical criteria
Preferred Qualifications

Experience evaluating clinical documentation, reviewer determinations, audit results, and compliance with state or health plan requirements
Experience with quality improvement methods, audit tools, performance measurement, inter-rater reliability, or clinical staff education required or strongly preferred
Experience with AI-assisted clinical review, clinical decision support, automation, or technology-enabled UM workflows preferred

Strong analytical, critical thinking, and clinical judgment skills
Ability to interpret and apply Medicaid policies, contract requirements, clinical criteria, and quality standards
Strong written, verbal, facilitation, presentation, and training skills
Ability to provide objective, respectful, and actionable feedback to clinical staff and leaders
Proven ability to identify trends, perform root-cause analysis, and support sustainable process improvement
Ability to work independently, manage competing priorities, meet deadlines, and maintain confidentiality
Proficient in Microsoft Office and comfortable learning quality reporting, audit, UM, and workflow technology platforms