Quality of Care Nurse

Mass General Brigham•Somerville, MA

22h•Remote

About The Position

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. 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. We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more. 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. 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.

Requirements

Bachelor's Degree Nursing required or Master's Degree Nursing preferred
Massachusetts Registered Nurse (RN) license required
At least 3-5 years of experience in clinical nursing with a focus on quality assurance, auditing, or a related field required
At least 2 years of clinical audit experience highly preferred
At least 2 years of experience in a health plan or managed care setting highly preferred
At least 1-2 years of familiarity with CMS, NCQA, Joint Commission, and state reporting requirements preferred
Experience in quality improvement, utilization management, risk management, or clinical auditing highly preferred
Strong working knowledge of: Serious Reportable Events / Sentinel Events
Root Cause Analysis and corrective action planning
Evidence-based clinical standards
Strong clinical judgment and critical thinking skills
Excellent written and verbal communication, including executive-level reporting
High attention to detail and ability to manage complex case reviews
Proficient in electronic medical records (EMRs), claims systems, and quality databases
Ability to work independently while collaborating across interdisciplinary teams
Comfortable handling sensitive, high-risk, and confidential information

Nice To Haves

CPHQ (Certified Professional in Healthcare Quality), CPPS (Certified Professional in Patient Safety), and/or CCM, RN-BC, (or similar) preferred
Strong leadership skill preferred

Responsibilities

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
Determine SRE eligibility and classification according to federal, state, accreditation, and organizational standards
Evaluate clinical documentation, medical records, incident reports, and claims related to SREs
Validate Root Cause Analyses (RCAs) and Corrective Action Plans (CAPs) for adequacy, sustainability, and compliance
Conduct quality-of-care reviews to assess adherence to evidence-based clinical standards, policies, and best practices
Identify deviations from standards of care and assess potential patient harm
Apply recognized quality frameworks (e.g., CMS, NCQA, Joint Commission, state-specific criteria) in audit findings
Develop audit reports that clearly outline findings, risk levels, and recommendations
Ensure compliance with CMS, state Department of Health, accreditation bodies, and contractual requirements
Support internal and external audits, regulatory reviews, and survey readiness related to SREs and quality issues
Monitor trends to identify systemic risks and emerging quality or safety concerns
Track, trend, and analyze SRE and quality-of-care data to identify patterns and opportunities for improvement
Prepare executive-level and committee reports summarizing findings, trends, and corrective actions
Collaborate with analytics and quality teams to support dashboards and quality metrics
Serve as a clinical resource to quality, compliance, risk management, and provider relations teams
Provide clinical input to multidisciplinary committees (e.g., Quality Improvement, Patient Safety, Credentialing)
Support education efforts related to patient safety, event reporting, and quality improvement strategies