Quality of Care Nurse
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Job Location:
Somerville, NJ - USA
Monthly Salary:
$ 63648 - 90750
Posted on:
4 hours ago
Vacancies:
1 Vacancy
Job Summary
Site: Mass General Brigham Health Plan Holding Company Inc.
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 welcoming and supportive environment that embraces their unique and varied backgrounds experiences and skills.
We are pleased to offer competitive salaries and a benefits package with flexible work options career growth opportunities and much more.
The Sr Clinical QA Nurse Auditor will focus auditing efforts on Quality of Care Serious Reportable Events (SRE) and Potentially Preventable Complications (PPC). The Nurse Auditor is responsible for reviewing auditing and analyzing serious reportable events adverse events and quality-of-care concerns to ensure patient safety regulatory compliance and continuous quality improvement. This role uses clinical expertise and auditing standards to identify trends validate root cause analyses and recommend system-level improvements to prevent recurrence. The Nurse Auditor will provide support to the clinical department through the evaluation of data records and reports to ensure compliance with regulatory standards.
The Quality of Care Nurse partners across the organization to support system enhancements develop and maintain policies and procedures and design tools and workflows that ensure accurate complete and compliant quality reviews and documentation. This role collaborates in interdisciplinary meetings and serves as a key clinical resource engaging and supporting colleagues through clear communication active listening and a shared commitment to continuous quality improvement.
Essential Functions
Review and audit reported Serious Reportable Events and Potentially Preventable Complications through a data-driven approach (Never Events sentinel events adverse outcomes) for completeness accuracy and timeliness
Determine SRE eligibility and classification according to federal state accreditation and organizational standards
Evaluate clinical documentation medical records incident reports and claims related to SREs
Validate Root Cause Analyses (RCAs) and Corrective Action Plans (CAPs) for adequacy sustainability and compliance
Conduct quality-of-care reviews to assess adherence to evidence-based clinical standards policies and best practices
Identify deviations from standards of care and assess potential patient harm
Apply recognized quality frameworks (e.g. CMS NCQA Joint Commission state-specific criteria) in audit findings
Develop audit reports that clearly outline findings risk levels and recommendations
Ensure compliance with CMS state Department of Health accreditation bodies and contractual requirements
Support internal and external audits regulatory reviews and survey readiness related to SREs and quality issues
Monitor trends to identify systemic risks and emerging quality or safety concerns
Track trend and analyze SRE and quality-of-care data to identify patterns and opportunities for improvement
Prepare executive-level and committee reports summarizing findings trends and corrective actions
Collaborate with analytics and quality teams to support dashboards and quality metrics
Serve as a clinical resource to quality compliance risk management and provider relations teams
Provide clinical input to multidisciplinary committees (e.g. Quality Improvement Patient Safety Credentialing)
Support education efforts related to patient safety event reporting and quality improvement strategiesRemote399 Revolution Drive40RegularDay (United States of America)8925 Mass General Brigham Health Plan Holding Company Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race color religious creed national origin sex age gender identity disability sexual orientation military service genetic information and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process to perform essential job functions and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973 the Vietnam Veterans Readjustment Act of 1974 and Title I of the Americans with Disabilities Act of 1990 applicants who require accommodation in the job application process may contact Human Resources at .
Mass General Brigham relies on a wide range of professionals including doctors nurses business people tech experts researchers and systems analysts to advance our mission. As a not-for-profit we support patient care research teaching and community service striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.
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 at 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 welcoming and supportive environment that embraces their unique and varied backgrounds experiences and skills.
We are pleased to offer competitive salaries and a benefits package with flexible work options career growth opportunities and much more.
The Sr Clinical QA Nurse Auditor will focus auditing efforts on Quality of Care Serious Reportable Events (SRE) and Potentially Preventable Complications (PPC). The Nurse Auditor is responsible for reviewing auditing and analyzing serious reportable events adverse events and quality-of-care concerns to ensure patient safety regulatory compliance and continuous quality improvement. This role uses clinical expertise and auditing standards to identify trends validate root cause analyses and recommend system-level improvements to prevent recurrence. The Nurse Auditor will provide support to the clinical department through the evaluation of data records and reports to ensure compliance with regulatory standards.
The Quality of Care Nurse partners across the organization to support system enhancements develop and maintain policies and procedures and design tools and workflows that ensure accurate complete and compliant quality reviews and documentation. This role collaborates in interdisciplinary meetings and serves as a key clinical resource engaging and supporting colleagues through clear communication active listening and a shared commitment to continuous quality improvement.
Essential Functions
Review and audit reported Serious Reportable Events and Potentially Preventable Complications through a data-driven approach (Never Events sentinel events adverse outcomes) for completeness accuracy and timeliness
Determine SRE eligibility and classification according to federal state accreditation and organizational standards
Evaluate clinical documentation medical records incident reports and claims related to SREs
Validate Root Cause Analyses (RCAs) and Corrective Action Plans (CAPs) for adequacy sustainability and compliance
Conduct quality-of-care reviews to assess adherence to evidence-based clinical standards policies and best practices
Identify deviations from standards of care and assess potential patient harm
Apply recognized quality frameworks (e.g. CMS NCQA Joint Commission state-specific criteria) in audit findings
Develop audit reports that clearly outline findings risk levels and recommendations
Ensure compliance with CMS state Department of Health accreditation bodies and contractual requirements
Support internal and external audits regulatory reviews and survey readiness related to SREs and quality issues
Monitor trends to identify systemic risks and emerging quality or safety concerns
Track trend and analyze SRE and quality-of-care data to identify patterns and opportunities for improvement
Prepare executive-level and committee reports summarizing findings trends and corrective actions
Collaborate with analytics and quality teams to support dashboards and quality metrics
Serve as a clinical resource to quality compliance risk management and provider relations teams
Provide clinical input to multidisciplinary committees (e.g. Quality Improvement Patient Safety Credentialing)
Support education efforts related to patient safety event reporting and quality improvement strategies
Qualifications
Education
- Bachelors Degree Nursing required or Masters Degree Nursing preferred
Licenses and Credentials
- Massachusetts Registered Nurse (RN) license required
- CPHQ (Certified Professional in Healthcare Quality) CPPS (Certified Professional in Patient Safety) and/or CCM RN-BC (or similar) preferred
Experience
- At least 3-5 years of experience in clinical nursing with a focus on quality assurance auditing or a related field required
- At least 2 years of clinical audit experience highly preferred
- At least 2 years of experience in a health plan or managed care setting highly preferred
- At least 1-2 years of familiarity with CMS NCQA Joint Commission and state reporting requirements preferred
- Experience in quality improvement utilization management risk management or clinical auditing highly preferred
- Strong working knowledge of:
- Serious Reportable Events / Sentinel Events
- Root Cause Analysis and corrective action planning
- Evidence-based clinical standards
- Strong leadership skill preferred
Knowledge Skills and Abilities
- Strong clinical judgment and critical thinking skills
- Excellent written and verbal communication including executive-level reporting
- High attention to detail and ability to manage complex case reviews
- Proficient in electronic medical records (EMRs) claims systems and quality databases
- Ability to work independently while collaborating across interdisciplinary teams
- Comfortable handling sensitive high-risk and confidential information
Additional Job Details (if applicable)
Working Conditions
- This is a remote role that can be done from most US states
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay Range
$63648.00 - $90750.40/AnnualGrade
6EEO 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 People-Focused half Performance-Focused) 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:
IC
About Company
Patients at Mass General have access to a vast network of physicians, nearly all of whom are Harvard Medical School faculty and many of whom are leaders within their fields.
