Senior Registered Nurse
2 weeks ago
Mass General Brigham Health Plan is seeking a highly skilled and experienced Registered Nurse to join our team as a Sr. Clinical Quality Assurance Nurse Auditor. As a key member of our Quality Management team, you will play a critical role in ensuring the highest level of quality performance and compliance with regulatory requirements and accreditation standards.
Job Summary:The Sr. Clinical Quality Assurance Nurse Auditor will be responsible for coordinating activities associated with clinical quality assurance, 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.
- 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.
- 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.
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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