Quality of Care RN

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances. Job Summary: The Quality of Care RN is responsible for regulatory quality of care review, which includes processing and evaluating complaints for determination of quality of care concerns, as per regulatory requirements. This individual provides clinical evaluation, support and oversight of Quality of Care including operational improvements related to regulatory requirement, and works with leaders at all levels throughout the company and with the state to ensure the success of the program and compliance. Our Investment in You: • Full-time remote work • Competitive salaries • Excellent benefits Key Functions/Responsibilities: • Receive and document complaints received regarding potential quality of care concerns • Conduct clinical review of complaints received for quality of care concerns • Document and present cases to Medical Director for clinical review and decision • Track results of cases presented and outcomes of the clinical reviews • Review medical records as needed for quality of care and other corporate initiatives Use clinical knowledge to provide assessment of data contained within medical record • Meet quality and timeliness standards to achieve individual and departmental performance goals as defined within the department guidelines • Consult and coordinate with various internal departments, external providers, vendors, businesses and government agencies to obtain information to meet departmental projects and goals • Document and record facts in regards to inquiries, correspondences and projects by updating files and systems • Demonstrate and maintain current working knowledge of the required systems, procedures, forms and manuals • Comply with all state and federal regulations for activities performed • Create and Maintain policies & standard operating procedures of processes to maintain compliance • Other duties as assigned Qualifications: Education Required: • Associate's Degree general field of study, or post high school nursing diploma Education Preferred: • Bachelor's, Master’s, or PhD in Nursing Experience Required: • 2 years of experience as practicing RN in hospital/healthcare setting Experience Preferred/Desirable: • 2+ years of experience in health insurance field • 2+ years of experience processing potential quality inquiries • Behavioral health experience in hospital or health plan setting Required Licensure, Certification or Conditions of Employment: • Valid Registered Nurse License required Competencies, Skills, and Attributes: Required Job Skills: • Intermediate skill in use of office equipment including copier, fax machine, scanner and telephones • Intermediate PC proficiency Intermediate skill in word processing, spreadsheet and database software Preferred Job Skills: • Advanced PC proficiency Required Professional Competencies: • Health care payer business knowledge including processes and operational data and functions that support the business • Maintain confidentiality and privacy • Capable of investigative and analytical research to make decisions and recommendations based on available information • Independent and sound judgment with good problem solving skills • Knowledge of managed care, utilization management, and quality management • Establish and maintain working relationships with health care providers, members and coworkers • Strong verbal and written communication skills and the ability to compose a variety of business correspondence and interact professionally with a diverse groups, executives, managers, and subject matter experts • Practice interpersonal and active listening skills to achieve customer satisfaction and departmental communication standards • Ability to Interpret policies, programs and guidelines • Establish and maintain working relationships in a collaborative team environment • Organizational skills with the ability to prioritize tasks and work with multiple priorities • Maintains current knowledge of State, Federal and other applicable regulatory/accrediting agency requirements as they apply to department functions Required Leadership Experience and Competencies: • Ability to use available information to focus project's scope and identify priorities • Ability to coordinate/lead small projects • Represent WellSense in the community About WellSense WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees Apply tot his job Apply To this Job