Sr. Clinical Reviewer & Trainer, Quality, Care Coordination

Who we are:

IHCS provides an Integrated Delivery System in the home setting, which includes, DME, Respiratory, Home Health and Home Infusion services. IHCS has a select network of Medicare and/or Medicaid Certified and Accredited providers to respond to the needs of our patients – 24/7. We operate with the sole intent of providing the highest quality in-home care services that improve and enhance the daily living for our patients, where our patients are #1.

With over 15 years of experience, we are the trusted market leader in Home Health, Durable Medical Equipment, and Home Infusion Services. If you are passionate about inspiring, motivating, and leading teams this opportunity could be for you and we want to hear from you!

Join our team as we strive for excellence through teamwork. We are committed to delivering high quality care to our patients through Exceptional Customer Service, Proven Outcomes, and Seamless Care.

Full time team members competitive compensation package, include but not limited to:

• Medical, Vision, Dental, Short- and Long-term insurance
• Paid Federal Holidays
• 16+ days of PTO
• Employer paid life insurance
• 401K with employer contribution
• Wellness program with reward incentives
• Employee recognition and reward programs

What You Will Be Doing

This position is responsible for conducting comprehensive audits of clinical documentation, operational processes, and administrative procedures to identify areas of non-compliance, mitigate risks, and drive continuous quality improvement. The Senior Quality Reviewer will interpret and apply federal, state (Florida), and local regulations, including Medicare/Medicaid guidelines, to ensure adherence and prepare the organization for successful audits and surveys. This individual will also be in charge of training creation and facilitation across the clinical team.

Key Responsibilities

• Support compliance and quality initiatives by identifying and developing the ongoing needs of the department, providing input toward solutions to audit findings, and developing, running, establishing, monitoring, and recommending improvements to internal audits.
• Ensure compliance with Federal and State regulations, contractual requirements, NCQA, CMS/ODAG, HIPAA, URAC, and payer guidelines while supporting the prevention, detection, and elimination of fraud, waste, and abuse across the organization.
• Remain current on health plan regulations and ensure the compliance team is informed of relevant updates.
• Escalate critical issues or potential concerns to the Compliance Officer/DME Director and represent the department in meetings or similar settings as needed.
• Lead and execute internal quality audits, risk assessments, and root‑cause analyses across clinical, administrative, and operational areas.
• Conduct detailed documentation audits for UM and CM case records, including UM determinations, NOMNC notices, care coordination notes, and other documentation types, ensuring accuracy, completeness, timeliness, and regulatory compliance.
• Serve as the documentation subject matter expert (SME), providing guidance on standards, best practices, and requirements.
• Develop audit plans, tools, workflows, and protocols aligned with regulatory, accreditation, and internal quality standards.
• Monitor corrective action plans (CAPs) through completion and provide coaching, follow-up support, and performance reinforcement to departments.
• Prepare audit summary reports, dashboards, and executive-level presentations that communicate performance trends, risk areas, and improvement opportunities.
• Serve as the lead liaison during external audits, surveys, or mock audits with regulators, payers, and accreditation bodies.
• Maintain, update, and refine SOPs, workflows, and work instructions related to QA and training functions.
• Design, develop, and deliver targeted training programs based on audit findings, knowledge gaps, regulatory updates, and workflow changes, applying adult learning principles and competency‑based methods.
• Create job aids, workflows, quick-reference guides, and other training materials to support staff education and documentation excellence.
• Partner with leaders and frontline teams to improve documentation quality, operational consistency, and compliance across departments.
• Facilitate calibration and IRR (inter-rater reliability) sessions to ensure scoring accuracy and consistency among auditors and reviewers.
• Assist with onboarding, mentoring, and development of QA staff, audit interns, and other team members.
• Identify and recommend workflow improvements, process efficiencies, automation opportunities, and best practices across operational areas.
• Collaborate with Quality Improvement, Compliance, Operations, Medical Management, and other cross-functional partners to support enterprise-level initiatives.
• Participate in quality committees and organization-wide projects focused on regulatory readiness, process improvement, and staff development.
• Ensure audit documentation is consistent, organized, accessible, and compliant with internal readiness-review expectations.

Qualifications

• Knowledge of health, home care, manager care, hospital and hospice care.
• Experience in care management; including care plan development and maintenance, care coordination and ability to interpret insurance policy language preferred.
• Minimum 3 years of progressive experience in quality auditing, regulatory compliance, or performance improvement within healthcare, managed care, or life sciences.
• 3 years of clinical experience as an RN.
• Active/Valid RN License in the state of Florida
• Demonstrated knowledge of CMS regulations, NCQA accreditation standards, Medicaid/Medicare guidelines, and HIPAA requirements.

Join our team as we strive for excellence through teamwork, where our patients are #1!

IHCS is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.