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Clinical Operations Quality Assurance RN
Job Description
Clinical Operations Quality Assurance Nurse
Quality Assurance Nurse plays a lead role in identifying and developing strategies and implementation plans to improve performance of a business unit or functional process through (a) analysis of current state (performance and root causes), (b) design of improved and development of new functions, processes, and/or tools to optimize outcomes, (c) and integration of industry best practices and, as applicable, cutting edge innovations into CCA.  The Quality Nurse is the interface between the business unit and Regulatory Affairs and Compliance.
  • Conduct audits to assure that regulatory and organizational standards are being met.(Example include: Departmental Metrics of Service Decisions, Pended claims, Documentation standards)
  • Analyze data to provide insights into strategic clinical and operational improvements and provide reporting to Clinical Operations team, Performance Improvement team and Regulatory Compliance Team.
  • Monitors compliance with Quality Improvement requirements.
  • Use established tools and techniques to assess and improve key clinical and other operational functions and supporting processes.
  • Conduct root cause analyses of Clinical Operations identified issues and develops process improvement plans in response to findings.
  • Identify and assist in developing improvement opportunities and other innovations including education, performance improvement plan or Corrective Action Plan.
  • Represents department in meetings and calls with internal business partners and MassHealth (Examples include: NONC, OneCare, Senior Care Options, Frail Elderly Waiver).
  • Tracking and coordinate Reinsurance efforts.
  • Maintain CCA’s position as a leader in care coordination and delivery.
  • Support continued transformation of the organization through general promotion of continuous learning and improvement and explicit training
  • Collaborate with CCA Quality Program staff to support additional prioritized quality improvement efforts, clinical programs, and other analytics and reporting initiatives
  • Other duties assigned
Expectations of all employees
Demonstrate integrity by working with passion, commitment, and honesty, acting in the best interests of colleagues and members. Approach work in a collaborating and caring manner interacting with insight, sincerity, and compassion. Demonstrate accountability by delivering on commitments, owning mistakes as well as successes, and contributing to an empowering environment where the focus is on solving problems and learning from errors. Recognize and respect diversity in all forms. Strive for excellence in the fulfillment of CCA’s mission through quality, innovation, and continuous learning. Demonstrate initiative, flexibility, and openness to change. Represent CCA and its clinical affiliates with professionalism. Keep current and proficient with necessary skills and knowledge. Self-identify training and development needs relevant to work area and responsibilities. Adhere to all applicable compliance requirements including but not limited to:
  • Complete required compliance training in a timely manner
  • Review Code of Conduct at least annually and promote and enforce CCA’s Code of Conduct
  • Promote and enforce CCA’s compliance program
  • Adhere to CCA’s Policy & Procedures
  • Promptly, in good faith, report any instances of suspected fraud, waste and abuse; suspected privacy
and/or security incidents; or any compliance concerns identified
  • Ensure confidentiality of member and company proprietary information is maintained
Minimum Education
BS in Nursing or Equivalent
Min years of experience
5+ years as RN
3 years preferred in Managed Care/ Health Plan
Knowledge, skills, ability
  • Experience in managed healthcare preferred (Medicare/MassHealth)
  • Experience in Quality Improvement and performance improvement
  • Experience in staff education preferred
  • Skilled in analytical reasoning and interpretation of complex information
  • Strong written and verbal communication skills and capacity to effectively communicate
  • Strong sense of empathy
  • Ability to think strategically
  •  Ability to work independently and as part of a team
  •  Ability to perform duties with accuracy and attention to detail
 Computer skills: Microsoft Word; Excel; PowerPoint;
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