Sr Clinical QA Nurse Auditor
 Mass General Brigham Health Plan | |
 United States, Massachusetts, Somerville | |
| 399 Revolution Drive (Show on map) | |
 Mar 14, 2025 | |
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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. 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 Inter-rater 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 MD's and any updates as needed. * Proctors/administers the Inter-rater 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 people-first organization. * Other duties as assigned with or without accommodation. Education Bachelor's Degree Nursing required or Master's Degree Nursing preferred Can this role accept experience in lieu of a degree? No Licenses and Credentials Registered Nurse [RN - State License] - Generic - HR Only preferred Experience Experience in clinical nursing with a focus on quality assurance, auditing, or a related field 3-5 years required Knowledge, Skills and Abilities - In-depth knowledge of healthcare regulations, accreditation standards, and quality improvement methodologies. - Strong analytical and problem-solving skills. - Excellent communication and interpersonal skills. - Proficiency in data analysis tools and Microsoft Office Suite. - Ability to work collaboratively in a team environment. Physical Requirements Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. 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. | |