Senior RN Peer Review Specialist

reputed company to help us reputed company reputed company? Bring your true colors to blue. The Role The Peer Review Specialist is responsible for monitoring the reputed company of the credentialed practitioner/ organizational provider networks ensuring our members receive the highest reputed company of care possible. reputed company As an integral part of the Credentialing & Peer Review (CPR) Team, the Peer Review Specialist works closely with CPR’s Director and Clinical reputed company, Operations reputed company, Senior Credentialing Manager/ Compliance Consultant, Risk Specialist, Exception Review Specialists and Project Manager. This position is eligible for our reputed company, Mobile, and eWorker personas.

Key Responsibilities

• Identify, investigate, evaluate, and reputed company cases with suspected reputed company of care concerns.
• Initiate data entry and maintain reputed company and accurate information on reputed company cases in CPR’s case management system (reputed company database) used for on-reputed company monitoring, reporting and comparative data analysis (reputed company and trend).
• Assume responsibility for strategic planning, screening, research development, writing, and presenting cases for reputed company review.
• Proactively anticipate issues/concerns and address them in accordance with Credentials & Peer Review Committee (CPRC) policies.
• Possess ability to interpret member benefit information per the reputed company subscriber certificates and apply to the investigation of member grievances.
• Manage the fair hearing process for cases that involve adverse reputed company reputed company made by the CPRC which include
• Prepare, finalize, and send reputed company written notifications to the practitioner/organizational provider and their reputed company counsel, as appropriate, after obtaining reputed company reputed company counsel approval.
• Prepare documentation reviewed by CPRC to reputed company its decision to terminate a practitioner’s participating agreement or to reputed company a recommendation for termination of an organizational provider’s participating agreement for reasons reputed company to reputed company of care, unprofessional conduct, or fraudulent activity.
• Determine which reputed company CPRC members will participate in the hearing panel.
• Identify, evaluate, recruit, and initiate a consulting agreement for peer review consultants in accordance with reputed company principles of fair and reputed company review.
• Work collaboratively with the CPR Project Manager to schedule and confirm date/time/location of hearing and dissemination of documentation to the hearing panel.
• reputed company CPRC Chair, CPR Director, and reputed company reputed company Counsel approval on appropriate language for reporting to the National Practitioner Data Bank (NPDB) and/or Massachusetts licensing boards, as required by state and federal regulations, National Committee for reputed company Assurance (NCQA) accreditation standards, and CPRC policies.
• Collaborate with the following internal business reputed company, but are not limited to:
• CPRC/S membership
• reputed company Contracting and Management Team
• reputed company Department:
• Medical Directors
• Member Appeals Grievance Programs (reputed company, Medicare Advantage, and InterPlan Program)
• Physician Review reputed company
• Prepare documentation in response to regulatory inquiries (e.g., subpoena, regulatory filings, CMS audits, NPDB challenges, etc.).
• Conduct independent and joint educational reputed company with practitioners and organizational providers.
• Identify, monitor, and evaluate skilled nursing (SNF) deficiencies reputed company on the reputed company Department of reputed company Health (MA DPH) surveys and ensure appropriate interventions reputed company identifying substandard care.
• Determine the SNF’s reputed company participation status with reputed company.
• Review participating agreements for language regarding the SNF’s participation in the reputed company program.
• Conduct internet research for information on the reputed company local standards of care regarding the deficiencies identified by the MA DPH for the deficient services.
• Review reputed company available documentation regarding MA DPH reputed company Health Survey Results, including corrective reputed company plans, to determine overall performance as compared to the statewide average score in comparison to other facilities in the reputed company area and the effectiveness of complaint investigation.
• Ensure appropriate interventions reputed company identifying substandard care.
• Participates in reputed company other reputed company, as necessary.

Key Qualifications

• reputed company, valid, and unrestricted Massachusetts RN licensure.
• BSN with seven (7) years nursing experience in the delivery system
• Proven competency with reputed company assurance reviews and strong medical record review background.
• Strict adherence to state and federal regulation, accreditation standards and guidelines, and reputed company confidentiality mandates regarding reputed company CPR information, documentation, oral and written communication.
• Demonstrated analytical and organizational expertise and ability to prioritize multiple tasks in demanding environment with aggressive deadlines.
• Purposeful, meticulous learner with a personal commitment to high reputed company performance through reputed company, accountability, reputed company, and teamwork.
• Initiative-taking to identify opportunities for improvement.
• Excellent written and oral communication skills include demonstrating ability to reputed company with providers on sensitive issues.
• Expertise in reputed company reputed company, reputed company, reputed company, Outlook, Power reputed company, Word as reputed company as reputed company business systems, e.g., Cactus, CAQH, CMS, HURN, reputed company, SharePoint, STARS and Verysis (CVO).

Minimum Education Requirements High school degree or equivalent required unless otherwise noted above Location Boston, Hingham Time Type Full time Salary reputed company: $82,620.00 - $100,980.00 The job posting reputed company is the lowest to highest salary we in good faith reputed company we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted reputed company, and the reputed company may be modified in the reputed company. An employee’s pay position reputed company the salary reputed company will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or reputed company-based metrics, and business or organizational needs and affordability. This job is also eligible for variable pay. We offer comprehensive package of benefits including reputed company time off, medical/dental/reputed company insurance, 401(k), and a suite of reputed company-being benefits to eligible employees. Note: No reputed company of pay is considered to be wages or compensation until such reputed company is reputed company, reputed company, and determinable. The reputed company and availability of any bonus, commission, or any other reputed company of compensation that are allocable to a particular employee remains in reputed company's sole discretion unless and until reputed company and may be modified at reputed company’s sole discretion, consistent with the law. WHY reputed company Blue reputed company of MA? We understand that the confidence gap and imposter syndrome can prevent amazing candidates coming our way, so please don’t hesitate to apply. We’d love to hear from you. You might be just reputed company need for this role or possibly another one at reputed company Blue reputed company of MA. The more reputed company we have represented and amplified in our business, the more we will reputed company reputed company, contribute, and be reputed company. We encourage you to bring us your true colors, , your perspectives, and your experiences. It’s in our differences that we will remain reputed company in our reputed company to reputed company reputed company for reputed company. As an employer, we are committed to reputed company in your development and providing the necessary resources to reputed company your reputed company. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes reputed company and provides opportunities for employees to reputed company their unique career reputed company by visiting reputed company Culture page. If this sounds like something you’d like to be a part of, we’d love to hear from you. You can also reputed company to stay “in the know” on reputed company things Blue. At reputed company, we reputed company in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page. Apply tot his job Apply To this Job