Clinical Review Senior Specialist

GENERAL DESCRIPTION: Responsible for conducting clinical quality audits through the review of medical records to ensure compliance with local and federal regulations. Identifies opportunities for improvement in provider performance and promotes the implementation of corrective and educational actions aligned with initiatives and project objectives. ESSENTIAL FUNCTIONS: Review medical records as part of assigned projects to evaluate provider performance and ensure alignment with quality standards (HEDIS/STARS, Quality Programs). This supports accurate quality reporting and improved patient outcomes.

Document audit results and activities in a timely and detailed manner to maintain accurate records for monitoring progress and ensuring accountability in quality initiatives. Identify deficiencies or areas of opportunity in provider documentation and care delivery through audit findings and recommend corrective actions to enhance compliance and care quality. Develop and deliver educational sessions tailored to identified gaps, helping providers and internal teams understand quality standards and improve clinical documentation and care practices. Follow up on the implementation of corrective action plans to evaluate progress, close performance gaps, and ensure continuous improvement in quality metrics.

Participate in quality improvement projects aimed at influencing HEDIS/STARS scores and meeting performance targets, contributing to the organization’s accreditation and reimbursement goals. Perform peer quality reviews of clinical assessments completed by other reviewers to ensure consistency, accuracy, and adherence to audit guidelines. Provide regular reports (weekly and monthly) to supervisors on audits completed, findings identified, and education delivered, to support data-driven decision-making. Maintain effective communication with internal and external stakeholders to ensure issues are addressed promptly and refer complaints or risks appropriately according to established procedures.

Stay current on clinical guidelines and regulatory requirements (Medicare, Medicaid, NCQA), ensuring all evaluations and recommendations are evidence-based and compliant with up-to-date standards. Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices. May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document. MINIMUM QUALIFICATIONS: Education and Experience: Bachelor of Science in Nursing.

At least five (5) years of clinical experience performing duties in a similar position. Certifications/Licenses: Nurse & Nurse Associations of Puerto Rico. A valid driver's license in the Commonwealth of Puerto Rico is required. Other: Proficiency in basic rules of medical record documentation and diagnosis validation, preferably. Car in good conditions and availability to travel to different locations in Puerto Rico. Languages:

Spanish – Advanced (comprehensive, writing and verbal)English – Advanced (comprehensive, writing and verbal)“Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento”