Senior RN Peer Review Specialist

The Role:
The Peer Review Specialist is responsible for monitoring the quality of the credentialed practitioner/ organizational provider networks ensuring our members receive the highest quality of care possible.

The Team:
As an integral part of the Credentialing & Peer Review (CPR) Team, the Peer Review Specialist works closely with CPR's Director and Clinical Lead, Operations Lead, Senior Credentialing Manager/ Compliance Consultant, Risk Specialist, Exception Review Specialists and Project Manager.

This position is eligible for our 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 on-going monitoring, reporting and comparative data analysis (track and trend).
• 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 which include
  • 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 the following internal business units, but are not limited to:
  • CPRC/S membership
  • Healthcare Contracting and Management Team

• Legal Department:
  • 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.
• 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 as compared to the statewide average score in comparison to other facilities in the same area and the effectiveness of complaint investigation.
• Ensure appropriate interventions when identifying substandard care.
• Participates 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 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 include demonstrating 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).

#LI-Remote

High school degree or equivalent required unless otherwise noted above

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that theconfidence gapandimposter syndromecan prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting ourCompany Culturepage. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join ourTalent Communityto stay "in the know" on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe 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.