Senior RN Peer Review Specialist

Blue Cross Blue Shield of Massachusetts is a community-focused, tax-paying, not-for-profit health plan headquartered in Boston. We have been a market leader for over 80 years, and are consistently ranked among the nation's best health plans. Our daily efforts are dedicated to effectively serving our 3 million members, and consistently offering security, stability, and peace of mind to both our members and associates. As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. We are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path. We take pride in our diverse, community-centric, wellness-focused culture and believe every member of our team deserves to enjoy a positive work-life balance. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation or gender identity.

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.

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.