Registered Nurse – Training and Quality Control Coordinator

Broadway Ventures is seeking a qualified Registered Nurse – Training and Quality Control Coordinator to support medical review operations for Palmetto GBA. This role is responsible for reviewing medical review decisions for accuracy, ensuring proper application of CMS guidelines, supporting quality control initiatives, training clinical staff, and assisting with provider inquiries and appeals-related medical coverage issues.

The ideal candidate will have strong clinical judgment, experience applying CMS instructions and medical review procedures, and the ability to provide education, feedback, and quality assurance support to medical review teams.

The Registered Nurse – Training and Quality Control Coordinator will be responsible for the following:

• →Review medical review decisions for accuracy and ensure CMS instructions and guidelines are applied correctly.
• →Develop, implement, and support a quality control program designed to evaluate clinical staff’s technical knowledge and medical judgment.
• →Provide feedback to management and staff regarding quality review findings.
• →Deliver remedial training when necessary to address identified performance or knowledge gaps.
• →Assist provider service departments with medical coverage issues to ensure consistent application of CMS guidelines.
• →Respond to specific provider inquiries and appeals requests related to medical coverage and review decisions.
• →Develop and maintain departmental reference manuals used to support proper application of CMS instructions.
• →Provide continuing education workshops for medical reviewers on coverage issues, CMS updates, and medical advances.
• →Train new staff on CMS guidelines, medical review procedures, and internal review processes.
• →Prepare monthly reports for management outlining quality control results, adjustment data, and reopening results summaries.
• →Provide input to the medical review audit department regarding actions taken in response to provider billing practices to help identify and target potential program abuse.

• Active and unrestricted Registered Nurse license.
• Strong knowledge of CMS guidelines, medical review procedures, and healthcare coverage requirements.
• Experience reviewing medical documentation and applying clinical judgment to coverage or medical necessity decisions.
• Ability to evaluate clinical staff performance and provide constructive feedback.
• Experience developing or supporting quality control, quality assurance, or audit programs.
• Strong written and verbal communication skills.
• Ability to create reports, reference materials, training guides, and educational content.
• Strong organizational skills and attention to detail.
• Ability to work independently and collaborate with management, clinical staff, provider service teams, and audit departments.

• Prior experience with Medicare, Medicaid, CMS contractors, or healthcare claims review.
• Experience responding to provider inquiries, appeals, or coverage-related requests.
• Background in medical review, utilization review, quality assurance, auditing, or clinical education.
• Experience training clinical staff or developing continuing education workshops.
• Familiarity with provider billing practices and program integrity concepts.

• Advanced clinical assessment and medical judgment skills.
• Understanding of CMS instructions and their application to medical review decisions.
• Ability to identify trends, errors, and training needs through quality control reviews.
• Strong analytical skills for preparing monthly management reports.
• Ability to communicate complex medical coverage issues clearly and professionally.
• Commitment to accuracy, compliance, consistency, and continuous improvement.

After submitting your application, our recruiting team will review your qualifications. This may include a brief telephone interview or email communication to verify resume details and discuss compensation expectations. Interviews will be conducted with the most qualified candidates. Broadway Ventures conducts background checks and drug testing prior to the start of employment. Some positions may also require fingerprinting.

Broadway Ventures is an equal opportunity employer and a VEVRAA federal contractor. We do not discriminate against applicants or employees on the basis of race, color, religion, sex, national origin, age, disability, protected veteran status, or any other status protected by applicable law.

Reasonable accommodations are available for applicants with disabilities. Broadway Ventures utilizes the OFCCP-approved Voluntary Self-Identification of Disability Form (CC-305).