Qualifications & Experience

• 
  

  Licensure: Bachelor’s Degree in Nursing with an active and valid USRN license in Massachusetts.

  
  


• 
  

  Appeals & Grievances Experience: Minimum of 1 year of hands-on experience in Medicare Part C Appeals and Grievances workstreams.

  
  


• 
  

  Quality Assurance Background: 1–2 years of experience as a Quality Assurance Analyst or Quality Evaluator in a clinical BPO/CPO environment.

  
  


• 
  

  Regulatory Knowledge: In-depth understanding of CMS Medicare Part C Appeals regulatory standards and compliance requirements.

  
  


• 
  

  Clinical & Operational Insight: Strong knowledge of clinical terminology, medical necessity review, and healthcare insurance operations.

  
  


• 
  

  Audit Readiness: Experience supporting external audits, including CMS Program Audits and client-facing audits.

  
  


• 
  

  Mentoring Experience: Proven ability to coach and mentor new quality assurance staff.

  
  


• 
  

  Technical Proficiency:

  
  
  
  
  
  • 
    

    Experience with InterQual (Medicare/Medicaid) for at least 1 year.

    
    
  
  
  • 
    

    Proficient in Quality Audit Systems and Microsoft Office Suite.

    
    
  
  
  
  


• 
  

  Core Competencies:

  
  
  
  
  
  • 
    

    Excellent verbal and written communication skills.

    
    
  
  
  • 
    

    High attention to detail with strong documentation and scoring calibration abilities.

    
    
  
  
  • 
    

    Strong analytical, critical thinking, and problem-solving skills.

    
    
  
  
  • 
    

    Collaborative team player with effective coaching and interpersonal abilities.

    
    
  
  
  
  

Additional Requirements

• 
  

  Willing to work on-site with flexibility to align with US business hours and holidays.

  
  

Why You’ll Excel in This Role

You are a detail-oriented nursing professional with a strong regulatory background and a passion for quality improvement. You thrive in structured, audit-ready environments and are skilled at guiding both processes and people toward compliance and excellence. If you’re ready to apply your clinical and analytical expertise in a dynamic, compliance-focused role, we encourage you to apply.