Sr Clinical QA Nurse Auditor
Mass General Brigham Health Plan

Job Info

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This is a remote role with occasional (roughly 1x/every other month) onsite team meetings in Somerville, MA.

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 support of NCQA accreditation and other regulatory and quality improvement program requirements.

The Sr. Clinical Quality Assurance Nurse Auditor participates in 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

Qualifications
Qualifications:

• Registered Nurse with 5-10 years of clinical experience in a health care setting.
• 5-10 years of health care experience with 2 years of health plan/insurance experience.
• 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.

Skills/Abilities/Competencies:

• Excellent verbal and written communication skills.
• Experience using MS Office Suite and SharePoint or other document-sharing software.
• Understanding of project management and business practices.
• Results-oriented, self-starter, motivated, quick learner, resourceful with superior problem-solving skills.
• Strong organizational skills and attention to detail.
• Excellent planning, coordination, and facilitation skills.
• Respects the talent and unique contribution of every individual, culture and ethnic group and treats all people in a fair and equitable manner.
• Exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.
• Accountable for delivering high quality work
• Demonstrate Mass General Brigham Health Plans core brand principles of always listening, challenging conventions, and providing value.
• Bring fresh ideas forward by listening to and working with employees and the people we serve.
• Respect the talent and unique contributions of every individual and treat all people in a fair and equitable manner.
• Strong, demonstrated track record of an ability to execute on time, on budget, and on scope.
• Strong aptitude for technology-based solutions.
• Ability to inject energy, when and where it's needed.
• Current in healthcare trends.
• Demonstrated forward, visionary thinking; ability to see "what is" and envision "what could be."
• Ability to develop, introduce, defend, and gain support for a new ideas and approaches.
• Excellent leadership skills and leadership track record.
• Ability to translate and communicate complex topics in a variety of forums, tailoring communications to effectively fit and influence the targeted audience, strong executive presence, presentation, and communication skills. Strong verbal, active listening, and written communication skills required.
• Ability to view the long-range trends and cycles of the business and industry and see the "big picture."
• Ability to apply a variety of strategic frameworks to analyze problems and to guide and develop solutions.
• Ability to challenge the status quo and drive innovative thinking and the capability to successfully implement strategy.
• Excellent interpersonal skills, including the ability to influence others at all levels of an organization.
• Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.
• Unquestionable integrity.

About Us:

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.

EEO Statement
Mass General Brigham 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 the law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, perform essential job functions, and receive other benefits and privileges of employment.

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