Senior Registered Nurse

2 weeks ago

Cambridge, Massachusetts, United States The Judge Group Full time
Job Title: Sr. Clinical Quality Assurance Nurse Auditor

Mass General Brigham Health Plan is seeking a highly skilled and experienced Sr. Clinical Quality Assurance Nurse Auditor to join our team. As a key member of our Quality Assurance department, you will play a critical role in ensuring the highest level of quality and compliance in our clinical programs.

Job Summary:

The Sr. Clinical Quality Assurance Nurse Auditor will be responsible for coordinating and conducting clinical quality assurance activities, including the development and review of training materials, auditing of clinical team members, and preparation for NCQA audits. You will work closely with the Clinical Quality Assurance & HEDIS Manager to monitor, maintain, and support the clinical department to ensure compliance with regulatory requirements and accreditation standards.

Key Responsibilities:
  • Conduct monthly file audits for all file requirements.
  • Participate in and/or lead clinical Interrater 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.
  • 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.
  • Participate in the training of the InterQual products for new UM staff and MDs and any updates as needed.
  • Proctor/administer the Interrater Reliability Testing to applicable clinical staff.
  • Conduct Utilization Management chart reviews to ensure that Clinical Screening Criteria (InterQual) has been applied correctly.
  • 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.
  • Research pertinent information as requested.
  • Produce correspondence and maintain a chronological log/file.
Requirements:
  • Registered Nurse with 5+ years of clinical experience in a healthcare setting.
  • 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.
Skills/Abilities/Competencies:
  • Excellent verbal and written communication skills.
  • Experience using MS Office Suite and SharePoint or other document-sharing software.
  • Understanding of project management and business practices.
  • Results-oriented, self-starter, motivated, quick learner, resourceful with superior problem-solving skills.
  • Strong organizational skills and attention to detail.
  • Excellent planning, coordination, and facilitation skills.
  • Respects the talent and unique contribution of every individual, culture, and ethnic group and treats all people in a fair and equitable manner.
  • Exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.
  • Accountable for delivering high-quality work.
  • Demonstrates Mass General Brigham Health Plan's core brand principles of always listening, challenging conventions, and providing value.
  • Brings fresh ideas forward by listening to and working with employees and the people we serve.
  • Respect the talent and unique contributions of every individual and treat all people in a fair and equitable manner.
  • Strong, demonstrated track record of an ability to execute on time, on budget, and on scope.
  • Strong aptitude for technology-based solutions.
  • Ability to inject energy, when and where it's needed.
  • Current in healthcare trends.
  • Demonstrated forward, visionary thinking; ability to see what is and envision what could be.
  • Ability to develop, introduce, defend, and gain support for new ideas and approaches.
  • Excellent leadership skills and leadership track record.
  • Ability to translate and communicate complex topics in a variety of forums, tailoring communications to effectively fit and influence the targeted audience, strong executive presence, presentation, and communication skills.
  • Ability to view the long-range trends and cycles of the business and industry and see the big picture.
  • Ability to apply a variety of strategic frameworks to analyze problems and to guide and develop solutions.
  • Ability to challenge the status quo and drive innovative thinking and the capability to successfully implement strategy.
  • Excellent interpersonal skills, including the ability to influence others at all levels of an organization.
  • Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.
  • Unquestionable integrity.
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. We are pleased to offer competitive salaries, and a benefits package with flexible work options, career growth opportunities, and much more.

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