<p>Site: Mass General Brigham Health Plan Holding Company, Inc.</p> <p>Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.</p> <p>Job Summary</p> <p>Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at 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.</p> <p>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 welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills.</p> <p>We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more.</p> <p>The Sr Clinical QA Nurse Auditor will focus auditing efforts on Quality of Care, Serious Reportable Events (SRE), and Potentially Preventable Complications (PPC). The Nurse Auditor is responsible for reviewing, auditing, and analyzing serious reportable events, adverse events, and quality-of-care concerns to ensure patient safety, regulatory compliance, and continuous quality improvement. This role uses clinical expertise and auditing standards to identify trends, validate root cause analyses, and recommend system-level improvements to prevent recurrence. The Nurse Auditor will provide support to the clinical department through the evaluation of data, records, and reports to ensure compliance with regulatory standards.</p> <p>The Quality of Care Nurse partners across the organization to support system enhancements, develop and maintain policies and procedures, and design tools and workflows that ensure accurate, complete, and compliant quality reviews and documentation. This role collaborates in interdisciplinary meetings and serves as a key clinical resource, engaging and supporting colleagues through clear communication, active listening, and a shared commitment to continuous quality improvement.</p> <p>Essential Functions</p> <ul> <li>Review and audit reported Serious Reportable Events and Potentially Preventable Complications through a data-driven approach (Never Events, sentinel events, adverse outcomes) for completeness, accuracy, and timeliness </li><li>Determine SRE eligibility and classification according to federal, state, accreditation, and organizational standards </li><li>Evaluate clinical documentation, medical records, incident reports, and claims related to SREs </li><li>Validate Root Cause Analyses (RCAs) and Corrective Action Plans (CAPs) for adequacy, sustainability, and compliance </li><li>Conduct quality-of-care reviews to assess adherence to evidence-based clinical standards, policies, and best practices </li><li>Identify deviations from standards of care and assess potential patient harm </li><li>Apply recognized quality frameworks (e.g., CMS, NCQA, Joint Commission, state-specific criteria) in audit findings </li><li>Develop audit reports that clearly outline findings, risk levels, and recommendations </li><li>Ensure compliance with CMS, state Department of Health, accreditation bodies, and contractual requirements </li><li>Support internal and external audits, regulatory reviews, and survey readiness related to SREs and quality issues </li><li>Monitor trends to identify systemic risks and emerging quality or safety concerns </li><li>Track, trend, and analyze SRE and quality-of-care data to identify patterns and opportunities for improvement </li><li>Prepare executive-level and committee reports summarizing findings, trends, and corrective actions </li><li>Collaborate with analytics and quality teams to support dashboards and quality metrics </li><li>Serve as a clinical resource to quality, compliance, risk management, and provider relations teams </li><li>Provide clinical input to multidisciplinary committees (e.g., Quality Improvement, Patient Safety, Credentialing) </li><li>Support education efforts related to patient safety, event reporting, and quality improvement strategies </li></ul> <p>Qualifications</p> <p>Education</p> <ul> <li>Bachelor's Degree Nursing required or Master's Degree Nursing preferred </li></ul> <p>Licenses and Credentials</p> <ul> <li>Massachusetts Registered Nurse (RN) license required </li><li>CPHQ (Certified Professional in Healthcare Quality), CPPS (Certified Professional in Patient Safety), and/or CCM, RN-BC, (or similar) preferred </li></ul> <p>Experience</p> <ul> <li> <p>At least 3-5 years of experience in clinical nursing with a focus on quality assurance, auditing, or a related field required</p> </li><li> <p>At least 2 years of clinical audit experience highly preferred</p> </li><li> <p>At least 2 years of experience in a health plan or managed care setting highly preferred</p> </li><li> <p>At least 1-2 years of familiarity with CMS, NCQA, Joint Commission, and state reporting requirements preferred</p> </li><li> <p>Experience in quality improvement, utilization management, risk management, or clinical auditing highly preferred</p> </li><li> <p>Strong working knowledge of:</p> </li><li> <p>Serious Reportable Events / Sentinel Events</p> </li><li> <p>Root Cause Analysis and corrective action planning</p> </li><li> <p>Evidence-based clinical standards</p> </li><li> <p>Strong leadership skill preferred</p> </li></ul> <p>Knowledge, Skills, and Abilities</p> <ul> <li>Strong clinical judgment and critical thinking skills </li><li>Excellent written and verbal communication, including executive-level reporting </li><li>High attention to detail and ability to manage complex case reviews </li><li>Proficient in electronic medical records (EMRs), claims systems, and quality databases </li><li>Ability to work independently while collaborating across interdisciplinary teams </li><li>Comfortable handling sensitive, high-risk, and confidential information </li></ul> <p>Additional Job Details (if applicable)</p> <p>Working Conditions</p> <ul> <li>This is a remote role that can be done from most US states </li></ul> <p>Remote Type</p> <p>Remote</p> <p>Work Location</p> <p>399 Revolution Drive</p> <p>Scheduled Weekly Hours</p> <p>40</p> <p>Employee Type</p> <p>Regular</p> <p>Work Shift</p> <p>Day (United States of America)</p> <p>Pay Range</p> <p>$63,648.00 - $90,750.40/Annual</p> <p>Grade</p> <p>6</p> <p>At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.</p> <p>EEO Statement:</p> <p>8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.</p> <p>Mass General Brigham Competency Framework</p> <p>At Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.</p>