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Clinical Quality Assurance Reviewer

2 months ago

Quincy, Massachusetts, United States InsideHigherEd Full time

Healthcare Compliance Auditor

This role, under the guidance of the NIPR Manager, involves managing retrospective evaluations of MassHealth providers to ensure adherence to regulations and standards of care quality. The Healthcare Compliance Auditor works in conjunction with multiple departments to evaluate and scrutinize 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 on issues related to fraud, waste, and abuse
  • Oversee the formulation of policy modifications based on case evaluations
  • Partner with IT analytics for thorough case assessments
  • Compile detailed case evaluations and findings notifications
  • Engage with state and federal entities
  • Prepare presentations for the Board of Hearing and participate in appeals processes
  • Generate reports for MassHealth
  • Collaborate with legal teams regarding settlements

Required Qualifications

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

Additional Considerations

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