Sr Clinical QA Nurse Auditor
Sr Clinical QA Nurse Auditor
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Job Description
At Mass General Brigham we know it takes a surprising range of talented professionals to advance our missionfrom doctors nurses business people and tech experts to dedicated researchers and systems analysts. As a notforprofit organization Mass General Brigham is committed to supporting patient care research teaching and service to the community. We place great value on being a diverse equitable and inclusive organization as we aim to reflect the diversity of the patients we serve.
At Mass General Brigham we believe a diverse set of backgrounds and lived experiences makes us stronger by challenging our assumptions with new perspectives that can drive revolutionary discoveries in medical innovations in research and patient care. Therefore we invite and welcome applicants from traditionally underrepresented groups in healthcare people of color people with disabilities LGBTQ community and/or gender expansive first and secondgeneration immigrants veterans and people from different socioeconomic backgrounds to apply.
Job Summary
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 worlds 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.
The primary responsibility of the Sr. Clinical Quality Assurance Nurse Auditor will be the coordination of activities associated with clinical quality assurance activities including the development and review of training and auditing materials performing auditing of clinical team members including but not limited to Case/Care Management (CM) Utilization Management (UM) Disease Management (DM) and other clinical teams and preparation for the actual and mock NCQA audits. The Nurse Auditor will perform audits to evaluate individuals compliance with clinical processes National Committee for Quality Assurance (NCQA) standards regulatory requirements and of overall clinical program effectiveness and efficiency.
The Sr. Clinical Quality Assurance Nurse Auditor will work closely with the Clinical Quality Assurance & HEDIS Manager to monitor maintain and support the clinical department to maintain a high level of quality performance and comply with regulatory requirements and accreditation standards.
In addition the Nurse Auditor will work closely with the NCQA Quality Team and the Sr. Director Quality Assurance & Process Improvement on an as needed basis in the support of NCQA accreditation and other regulatory and quality improvement program requirements.
The Sr. Clinical Quality Assurance Nurse Auditor participates on departmental and organizational project teams and plays a critical role in project implementation by soliciting requirements through interviews workshops and/or existing systems documentation or procedures and ensuring that all impacted processes and systems are evaluated.
The Sr. Clinical Quality Assurance Nurse Auditor works closely with the Clinical Department in assisting with the definition documentation training and support for new required accreditation processes.
As a member of the Quality Management team the Sr. Clinical Quality Assurance Nurse Auditor will have an opportunity to support improved accessibility to key business information ensure process integrity and develop process flexibility which contributes to the success of Mass General Brigham Health Plan.
Principal Duties and Responsibilities:
Conduct monthly file audits for all file requirements.
Participate in and/or lead clinical Interrater Reliability Testing (IRR).
Proactively communicates and collaborates within the Clinical and Quality Departments to identify key areas of focus and helps to develop and maintain a Quality Assurance (QA) plan that includes auditing analyzing strategizing and developing process refinements and program improvements.
Develops written summaries of specific key areas of training required for clinical staff based on audit results and works on developing programs with Clinical Operations the Quality Assurance Manager and the NCQA team to help clinical staff gain proficiency in their work and documentation processes.
Monitors 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.
Works with the Clinical Quality Assurance Manager to communicate recommendations for operational changes based on survey findings to Quality and Clinical leadership.
Participates in training activities for clinical staff to support adherence to NCQA and other regulatory and internal documentation standards/requirements.
Participates in the training of the InterQual products for new UM staff and MDs and any updates as needed.
Proctors/administers the Interrater Reliability Testing to applicable clinical staff
Conducts Utilization Management chart reviews to ensure that Clinical Screening Criteria (InterQual) has been applied correctly.
Supports business requirements for system and process improvements.
Works with Medical Record Review staff to assist with the medical record review process.
Supports the Appeals and Grievance team to assist with auditing and compliance.
Research pertinent information as requested.
Produces correspondence and maintains a chronological log/file.
Hold self and others accountable to meet commitments.
Ensure diversity equity and inclusion are integrated as a guiding principle.
Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a peoplefirst organization.
Other duties as assigned with or without accommodation.
Qualifications
Additional Job Details (if applicable)
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
EEO Statement:
Mass General Brigham Competency Framework
At Mass General Brigham our competency framework defines what effective leadership looks like by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half PeopleFocused half PerformanceFocused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance make hiring decisions identify development needs mobilize employees across our system and establish a strong talent pipeline.
Required Experience:
Senior IC
Employment Type
Full-Time
