Appeals and Grievances Nurse

Mass General Brigham•Somerville, MA

23h•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. 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

Requirements

Bachelor's Degree in Nursing required
Massachusetts Registered Nurse (RN License) 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
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.

Responsibilities

In conjunction with other appeal team members, ensures that clinical/pharmacy appeals and grievances are resolved timely 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.
Reviews and analyzes clinical appeals and grievances to determine validity and appropriate course of action. Completes written summaries on clinical cases.
Tracks and monitors the status of appeals and grievances, ensuring timely resolution and follow-up.
Identifies trends and patterns in appeals and grievances to inform quality improvement initiatives.
Coordinates communication between patients, healthcare providers, and insurance companies regarding appeals and grievances.
Educates staff and patients about the appeals and grievances process to enhance understanding and compliance.
Participates in interdisciplinary meetings to discuss complex cases and recommend solutions.