Clinical Appeal and Grievance Nurse

Mass General Brigham • Somerville, MA

6d • Remote

About The Position

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.

Requirements

• 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
• 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.

Nice To Haves

• 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

Responsibilities

• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level