Clinical Appeal and Grievance Nurse

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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.

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.

• In conjunction with other appeal team members, ensures that clinical/pharmacy appeals and grievances are resolved in a timely manner to meet regulatory time frames.
• 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

• Bachelor's Degree required

• Massachusetts Registered Nurse (RN) required

• 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

• 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 Inter Qual Criteria
• Knowledge of Medicare national and local coverage determinations

• 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.

• This is a remote role with occasional onsite team meetings in Somerville, MA.
• Monday through Friday, eastern business hours required
• Remote workdays require a stable, secure, quiet, and HIPAA-compliant workspace. This will be confirmed via Microsoft Teams video for all employees

Remote

399 Revolution Drive

40

Regular

Day (United States of America)

$63,648.00 - $92,570.40/Annual

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…