Brigham and Women’s Hospital
Sr Clinical QA Nurse Auditor
Brigham and Women’s Hospital, Oklahoma City, Oklahoma, United States,
Job Description - Sr Clinical QA Nurse Auditor (3303739)Job Number:
3303739This is a remote role with occasional (roughly 1x/every other month) onsite team meetings in Somerville, MA.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 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 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 communicate and collaborate within the Clinical and Quality Departments to identify key areas of focus and help to develop and maintain a Quality Assurance (QA) plan that includes auditing, analyzing, strategizing, and developing process refinements and program improvements.Develop written summaries of specific key areas of training required for clinical staff based on audit results, and work 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.Monitor 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.Work with the Clinical Quality Assurance Manager to communicate recommendations for operational changes based on survey findings to Quality and Clinical leadership.Participate in training activities for clinical staff to support adherence to NCQA and other regulatory and internal documentation standards/requirements.Participate in the training of the InterQual products for new UM staff and MDs and any updates as needed.Proctor/administer the Inter-rater Reliability Testing to applicable clinical staff.Conduct Utilization Management chart reviews to ensure that Clinical Screening Criteria (InterQual) has been applied correctly.Support business requirements for system and process improvements.Work with Medical Record Review staff to assist with the medical record review process.Support the Appeals and Grievance team to assist with auditing and compliance.Research pertinent information as requested.Produce correspondence and maintain 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: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.InterQual experience preferred.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.
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3303739This is a remote role with occasional (roughly 1x/every other month) onsite team meetings in Somerville, MA.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 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 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 communicate and collaborate within the Clinical and Quality Departments to identify key areas of focus and help to develop and maintain a Quality Assurance (QA) plan that includes auditing, analyzing, strategizing, and developing process refinements and program improvements.Develop written summaries of specific key areas of training required for clinical staff based on audit results, and work 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.Monitor 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.Work with the Clinical Quality Assurance Manager to communicate recommendations for operational changes based on survey findings to Quality and Clinical leadership.Participate in training activities for clinical staff to support adherence to NCQA and other regulatory and internal documentation standards/requirements.Participate in the training of the InterQual products for new UM staff and MDs and any updates as needed.Proctor/administer the Inter-rater Reliability Testing to applicable clinical staff.Conduct Utilization Management chart reviews to ensure that Clinical Screening Criteria (InterQual) has been applied correctly.Support business requirements for system and process improvements.Work with Medical Record Review staff to assist with the medical record review process.Support the Appeals and Grievance team to assist with auditing and compliance.Research pertinent information as requested.Produce correspondence and maintain 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: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.InterQual experience preferred.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.
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