Blue Cross Blue Shield of Massachusetts
Senior RN Peer Review Specialist
Blue Cross Blue Shield of Massachusetts, Boston, Massachusetts, us, 02298
Senior RN Peer Review Specialist
Blue Cross Blue Shield of Massachusetts
Overview Ready to help us transform healthcare? Bring your true colors to blue.
The Role
The Peer Review Specialist monitors the quality of the credentialed practitioner and organizational provider networks, ensuring members receive the highest quality of care possible.
Team The Peer Review Specialist works closely with CPR Director, Clinical Lead, Operations Lead, Senior Credentialing Manager/Compliance Consultant, Risk Specialist, Exception Review Specialists, and Project Manager.
Position eligible for Resident, Mobile, and eWorker personas.
Key Responsibilities
Identify, investigate, evaluate, and develop cases with suspected quality of care concerns.
Initiate data entry and maintain timely and accurate information on all cases in CPR’s case management system (Access database) used for ongoing monitoring, reporting, and comparative data analysis.
Assume responsibility for strategic planning, screening, research development, writing, and presenting cases for internal and external 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 BCBSMA subscriber certificates and apply to the investigation of member grievances.
Manage the fair hearing process for cases that involve adverse action decisions made by the CPRC, including:
Prepare, finalize, and send all written notifications to the practitioner/organizational provider and their legal counsel, as appropriate, after obtaining BCBSMA legal counsel approval.
Prepare documentation reviewed by CPRC to make its decision to terminate a practitioner’s participating agreement or to make a recommendation for termination of an organizational provider’s participating agreement for reasons related to quality of care, unprofessional conduct, or fraudulent activity.
Determine which internal and external CPRC members will participate in the hearing panel.
Identify, evaluate, recruit, and initiate a consulting agreement for peer review consultants in accordance with BCBSMA principles of fair and equitable 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.
Seek CPRC Chair, CPR Director, and BCBSMA Legal 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 Quality Assurance (NCQA) accreditation standards, and CPRC policies.
Collaborate with internal business units, including:
CPRC/S membership.
Healthcare Contracting and Management Team.
Legal Department collaborations, including:
Medical Directors.
Member Appeals Grievance Programs (Commercial, Medicare Advantage, and InterPlan Program).
Physician Review Units.
Prepare documentation in response to regulatory inquiries (e.g., subpoena, regulatory filings, CMS audits, NPDB challenges, etc.).
Conduct independent and joint educational visits with practitioners and organizational providers.
Identify, monitor, and evaluate skilled nursing (SNF) deficiencies found on the Commonwealth of Massachusetts Department of Public Health (MA DPH) surveys and ensure appropriate interventions when identifying substandard care.
Determine the SNF’s current participation status with BCBSMA and review participating agreements for language regarding the SNF’s participation in the quality program.
Conduct internet research for information on the current local standards of care regarding the deficiencies identified by the MA DPH for the deficient services.
Review all available documentation regarding MA DPH Public Health Survey Results, including corrective action plans, to determine overall performance compared to the statewide average score and the effectiveness of complaint investigation.
Ensure appropriate interventions when identifying substandard care.
Participate in all other projects, as necessary.
Key Qualifications
Current, valid, and unrestricted Massachusetts RN licensure.
BSN with seven (7) years nursing experience in the delivery system.
Proven competency with quality assurance reviews and strong medical record review background.
Strict adherence to state and federal regulation, accreditation standards and guidelines, and Blue Cross confidentiality mandates regarding all CPR information, documentation, oral and written communication.
Demonstrated analytical and organizational expertise and ability to prioritize multiple tasks in a demanding environment with aggressive deadlines.
Purposeful, meticulous learner with a personal commitment to high quality performance through integrity, accountability, compassion, and teamwork.
Initiative-taking to identify opportunities for improvement.
Excellent written and oral communication skills including ability to interact with providers on sensitive issues.
Expertise in Microsoft Access, Adobe, Excel, Outlook, Power Point, Word as well as Blue Cross business systems, e.g., Cactus, CAQH, CMS, HURN, SalesForce, SharePoint, STARS and Verysis (CVO).
Minimum Education Requirements High school degree or equivalent required unless otherwise noted above.
Location Boston, Hingham, Massachusetts
Time Type Full time
Salary Range $82,620.00 - $100,980.00
Benefits Comprehensive package including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits.
Why Blue Cross Blue Shield of MA? We understand that confidence gap and imposter syndrome can prevent amazing candidates from our way. Bring us your true colors, perspectives, and experiences. We’re committed to investing in your development and providing resources to enable your success. Learn how we’re dedicated to creating an inclusive and rewarding workplace by visiting our Company Culture page. If this sounds like something you’d like to be part of, we’d love to hear from you.
#J-18808-Ljbffr
Overview Ready to help us transform healthcare? Bring your true colors to blue.
The Role
The Peer Review Specialist monitors the quality of the credentialed practitioner and organizational provider networks, ensuring members receive the highest quality of care possible.
Team The Peer Review Specialist works closely with CPR Director, Clinical Lead, Operations Lead, Senior Credentialing Manager/Compliance Consultant, Risk Specialist, Exception Review Specialists, and Project Manager.
Position eligible for Resident, Mobile, and eWorker personas.
Key Responsibilities
Identify, investigate, evaluate, and develop cases with suspected quality of care concerns.
Initiate data entry and maintain timely and accurate information on all cases in CPR’s case management system (Access database) used for ongoing monitoring, reporting, and comparative data analysis.
Assume responsibility for strategic planning, screening, research development, writing, and presenting cases for internal and external 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 BCBSMA subscriber certificates and apply to the investigation of member grievances.
Manage the fair hearing process for cases that involve adverse action decisions made by the CPRC, including:
Prepare, finalize, and send all written notifications to the practitioner/organizational provider and their legal counsel, as appropriate, after obtaining BCBSMA legal counsel approval.
Prepare documentation reviewed by CPRC to make its decision to terminate a practitioner’s participating agreement or to make a recommendation for termination of an organizational provider’s participating agreement for reasons related to quality of care, unprofessional conduct, or fraudulent activity.
Determine which internal and external CPRC members will participate in the hearing panel.
Identify, evaluate, recruit, and initiate a consulting agreement for peer review consultants in accordance with BCBSMA principles of fair and equitable 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.
Seek CPRC Chair, CPR Director, and BCBSMA Legal 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 Quality Assurance (NCQA) accreditation standards, and CPRC policies.
Collaborate with internal business units, including:
CPRC/S membership.
Healthcare Contracting and Management Team.
Legal Department collaborations, including:
Medical Directors.
Member Appeals Grievance Programs (Commercial, Medicare Advantage, and InterPlan Program).
Physician Review Units.
Prepare documentation in response to regulatory inquiries (e.g., subpoena, regulatory filings, CMS audits, NPDB challenges, etc.).
Conduct independent and joint educational visits with practitioners and organizational providers.
Identify, monitor, and evaluate skilled nursing (SNF) deficiencies found on the Commonwealth of Massachusetts Department of Public Health (MA DPH) surveys and ensure appropriate interventions when identifying substandard care.
Determine the SNF’s current participation status with BCBSMA and review participating agreements for language regarding the SNF’s participation in the quality program.
Conduct internet research for information on the current local standards of care regarding the deficiencies identified by the MA DPH for the deficient services.
Review all available documentation regarding MA DPH Public Health Survey Results, including corrective action plans, to determine overall performance compared to the statewide average score and the effectiveness of complaint investigation.
Ensure appropriate interventions when identifying substandard care.
Participate in all other projects, as necessary.
Key Qualifications
Current, valid, and unrestricted Massachusetts RN licensure.
BSN with seven (7) years nursing experience in the delivery system.
Proven competency with quality assurance reviews and strong medical record review background.
Strict adherence to state and federal regulation, accreditation standards and guidelines, and Blue Cross confidentiality mandates regarding all CPR information, documentation, oral and written communication.
Demonstrated analytical and organizational expertise and ability to prioritize multiple tasks in a demanding environment with aggressive deadlines.
Purposeful, meticulous learner with a personal commitment to high quality performance through integrity, accountability, compassion, and teamwork.
Initiative-taking to identify opportunities for improvement.
Excellent written and oral communication skills including ability to interact with providers on sensitive issues.
Expertise in Microsoft Access, Adobe, Excel, Outlook, Power Point, Word as well as Blue Cross business systems, e.g., Cactus, CAQH, CMS, HURN, SalesForce, SharePoint, STARS and Verysis (CVO).
Minimum Education Requirements High school degree or equivalent required unless otherwise noted above.
Location Boston, Hingham, Massachusetts
Time Type Full time
Salary Range $82,620.00 - $100,980.00
Benefits Comprehensive package including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits.
Why Blue Cross Blue Shield of MA? We understand that confidence gap and imposter syndrome can prevent amazing candidates from our way. Bring us your true colors, perspectives, and experiences. We’re committed to investing in your development and providing resources to enable your success. Learn how we’re dedicated to creating an inclusive and rewarding workplace by visiting our Company Culture page. If this sounds like something you’d like to be part of, we’d love to hear from you.
#J-18808-Ljbffr