Massachusetts Healthcare Jobs

Why This Role is Important to Us:

The QOC and HEDIS RN supports the Quality-of-Care Grievance/Concern and Critical Incident Report team investigation efforts to ensure comprehensive and timely completion of CMS and MassHealth regulations. This role will also serve to support the HEDIS Prospective Nurse Review team in the chart and medical review for HEDIS and other measure documentation.

Supervision Exercised: No

What You'll Be Doing:

Under the direction of the VP, Quality Programs and in partnership with the Quality Program's Quality of Care Specialist:

• Perform root cause analysis (RCA) of Quality-of-Care Grievances and Quality of Care Concerns submitted by members/authorized representatives and clinicians

• Complete RCA through review of clinical notes, nursing notes and other network-contracted and/or internal practitioners documents of care to determine if standards of care were met or whether the care provided was deficient

• Interview internal and external stakeholders, as appropriate, to ensure comprehensiveness of RCA to aid in most accurate decision possible

• Seek CCA clinician input to activities / care preceding the submission of QoC Grievance or Concern to determine possible drivers

• Collaborate with CCA Medical Directors, as appropriate, to identify any deficiencies in care

• As based on reliable evidence and RCA, construct comprehensive documentation text for member and provider response letters

• Clarify all foundational information of Critical Incident Reports, including predecendent events, to ensure accuracy and comprehensiveness of all reports provided to MassHealth

• Perform RCA to identify patterns/trends and 'avoidable events'

• Partner with CMO in developing strategies to offset avoidable incidents prior to occurrence

To support Prospective HEDIS Review Nurse functions, as needed:

• Identify, analyze, and abstract clinical information as it applies to HEDIS and NCQA requirements, integrating data collected from a variety of electronic and paper sources.

• Document abstracted findings into a HEDIS database tool

• Participate in annual record collection, abstraction, and documentation training

• Follow defined procedures for saving approved medical record documentation

• Perform quality assurance reviews of supplemental data medical records

Working Conditions:

• Standard office conditions.

What We're Looking For:

Education Required:

• Bachelor's Degree

Licensing Required:

• Licensed RN or LPN

Experience Required:

• 2+ years of recently HEDIS medical record abstraction

Experience Desired:

• 2+ years' experience in managed care environment

• CMS and Medicaid experience

Knowledge, Skills & Abilities Required:

• Knowledge of HEDIS measures

• Knowledge/familiarity with CMS

• Working knowledge of various EMR systems

• Knowledge/familiarly with MS Office

• Highly organized and detailed

• Self-motivated

• Can work toward tight timeframes in a frequently changing environment

Knowledge, Skills & Abilities Desired:

• Ability to maneuver in a matrix environment

• Excellent communicator

Language(s) Required:

• English

Other Required:

• Standard office equipment

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.