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Healthcare Compliance Nurse Reviewer

2 months ago


Quincy, Massachusetts, United States InsideHigherEd Full time

Healthcare Compliance Auditor

This role, under the guidance of the NIPR Manager, is tasked with managing retrospective evaluations of MassHealth providers to guarantee adherence to regulations and standards of care quality. The Healthcare Compliance Auditor works in collaboration with multiple departments to investigate and assess cases of potential fraud, waste, and abuse, delivering insights and recommendations to relevant stakeholders.

Key Responsibilities

  • Lead initiatives for policy enhancement within MassHealth
  • Serve as a subject matter expert regarding fraud, waste, and abuse
  • Oversee the formulation of policy modifications based on case evaluations
  • Partner with IT analytics for thorough case investigations
  • Compile detailed case evaluations and notices of findings
  • Engage with state and federal entities
  • Prepare presentations for the Board of Hearing and participate in appeal processes
  • Generate reports for MassHealth
  • Collaborate with legal teams for resolution agreements

Required Qualifications

  • Current RN, CNP, or PA-C license in Massachusetts
  • Master's degree in a relevant discipline
  • At least 10 years of clinical experience
  • Excellent communication and interpersonal abilities

Additional Information

  • Certifications in Case Management are preferred
  • Previous experience in diverse healthcare environments is advantageous