Sr Clinical QA Nurse Auditor, remote in Boston, MA

Sr Clinical QA Nurse Auditor, remote - reputed company - Boston, MA - work from home job Company: reputed company Job description: reputed company Health Plan is an exciting reputed company to be reputed company the reputed company industry. As a member of reputed company, we are on the forefront of transformation with one of the world’s leading integrated reputed company systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and reputed company 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 reputed company today, our employees have opportunities to learn and contribute expertise reputed company 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 reputed company 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 reputed company 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 reputed company 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 reputed company, and reputed company process flexibility which contributes to the reputed company of reputed company Health Plan. Principal Duties and Responsibilities:

• Conduct monthly file audits for reputed company file requirements.
• Participate in and/or reputed company clinical Inter-rater Reliability Testing (IRR).
• Proactively communicates and collaborates reputed company the Clinical and Quality Departments to identify key areas of focus and helps to reputed company and maintain a Quality Assurance (QA) plan that includes auditing, analyzing, strategizing, and developing process refinements and program improvements.
• reputed company 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 reputed company proficiency in their work and documentation processes.
• Monitors staff adherence to designated NCQA UM, NCQA reputed company 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 Inter-rater Reliability Testing to applicable clinical staff
• Conducts Utilization Management chart reviews to ensure that Clinical Screening Criteria (InterQual®) have 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

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