Senior Registered Nurse
2 weeks ago
Mass General Brigham is seeking a highly skilled Registered Nurse to join our team as a Senior Registered Nurse - Quality Assurance Specialist. This role will be responsible for coordinating clinical quality assurance activities, including the development and review of training materials, auditing, and preparing for NCQA audits.
Key Responsibilities:
- Conduct monthly file audits for all file requirements.
- Participate in and/or lead clinical Inter-rater Reliability Testing (IRR).
- Proactively communicate and collaborate within the Clinical and Quality Departments to identify key areas of focus and develop a Quality Assurance (QA) plan.
- Develop written summaries of specific key areas of training required for clinical staff based on audit results.
- Monitor staff adherence to designated NCQA UM, NCQA Complex Care Management (CCM), Quality Improvement (QI) and other standards, contractual and regulatory requirements with ongoing assessment of performance.
- Work with the Clinical Quality Assurance Manager to communicate recommendations for operational changes based on survey findings to Quality and Clinical leadership.
- Participate in training activities for clinical staff to support adherence to NCQA and other regulatory and internal documentation standards/requirements.
- Support business requirements for system and process improvements.
- Work with Medical Record Review staff to assist with the medical record review process.
- Support the Appeals and Grievance team to assist with auditing and compliance.
Requirements:
- Registered Nurse with 5-10 years of clinical experience in a health care setting.
- 5-10 years of health care experience with 2 years of health plan/insurance experience.
- Valid unrestricted Massachusetts RN professional license.
- Quality Assurance auditing experience a plus.
- NCQA experience preferred.
- Complex Care Management experience preferred.
- Utilization Management (InterQual) experience preferred.
About Us:
Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are on the forefront of transformation with one of the world's leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage. Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a consciously inclusive environment where diversity is celebrated.
Benefits:
- Medical benefits.
- Dental benefits.
- Vision benefits.
- Life insurance.
- Employee assistance programs.
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