Clinical Appeal and Grievance Nurse

Site: Mass General Brigham Health Plan Holding Company, Inc.

 

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

 

 

Job Summary

The role is an integral part of our Appeals and Grievance review process and will ensure clinical/pharmacy appeal case reviews meet contractual, regulatory, and business goals. The position collaborates with members of the Appeal and Grievance team, pharmacy team, and medical director teams to resolve all types of clinical issues across the clinical/pharmacy appeal landscape.

Essential Functions
• In conjunction with other appeal team members, ensures that clinical/pharmacy appeals and grievances are resolved in a timely manner to meet regulatory timeframes.
• Directly interact with providers and their staff to obtain additional clinical information as well as with members or their advocates to understand the full intent of the appeal or clinical grievance.
• Review clinical/pharmacy appeal cases and provide recommendations to the medical director team based on analysis of the clinical material.
• Interact closely with pharmacy staff on pharmacy-related reviews in preparation for physician review if needed
• Identify cases that may require specialty review and expedite submission of cases to our contracted vendor (s) for this purpose
• Analyze and complete written summaries on clinical cases.
• Maintain compliance with all required turnaround times
• Maintain compliance with all regulatory and NCQA requirements with regards to this important work

 

Qualifications

Education

• Bachelor's Degree required

Licenses and Credentials

• Massachusetts Registered Nurse (RN) required

Experience

• At least 3-5 years of experience in clinical appeals, grievances, utilization review, or related healthcare services required

• At least 2-3 years of clinical experience required

Preferred

• 5 years of experience working with members, providers, and internal staff on complex and sensitive requests for clinical services

• 5 years of experience working in multiple data systems

• Experience with multiple product lines, including Commercial, Exchange, Medicaid, and Medicare Advantage 

• Familiarity with InterQual Criteria

• Knowledge of Medicare national and local coverage determinations

Knowledge, Skills, and Abilities

• Strong analytical and critical thinking skills.

• Excellent verbal and written communication abilities.

• Proficient in using electronic health records (EHR) and billing systems.

• Detail-oriented with strong organizational skills.

• Ability to handle sensitive information with confidentiality and professionalism.

• Strong interpersonal skills to work effectively with various stakeholders.

 

Additional Job Details (if applicable)

Working Conditions

• While a remote role, this team meets every quarter at the office at Assembly Row in Somerville and attendance is highly encouraged.

 

Remote Type

Remote

 

Work Location

399 Revolution Drive

 

Scheduled Weekly Hours

40

 

Employee Type

Regular

 

Work Shift

Day (United States of America)

 

Pay Range

$62,400.00 - $90,750.40/Annual

 

Grade

6

 

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and supp