Clinical Appeal Nurse

Fallon Health • Worcester, MA

110d

About The Position

The Fallon Health Appeals and Grievance process is an essential function to Fallon Health’s compliance with CMS regulations, Medicaid, NCQA standards, other applicable regulatory requirements and member expectations. Under the direction of the Director, the Appeal Nurse represents, manages and oversees second level appeal cases (Office of Medicaid, Board of Hearings) and ensures compliance with appropriate regulatory standards. These appeals are in response to determination for medical items or services related to benefits or other related matters that are requested and the application of clinical criteria and medical necessity determinations. The Appeal Nurse is responsible for ensuring compliance with all applicable state and federal laws and regulations governing the work requirements. The Appeal Nurse is also responsible for presentation of the member appeal to the Plan Medical Director, Center for Medicare/Medicaid Services, contracted reviewer, and the Plan contracted external review agency in accordance with applicable laws, organization policies, and regulatory requirements. Thorough research, detailed documentation, and a well-defined corrective action plan must be developed for each individual case, with all effectuation carried out in full compliance with applicable regulations, policies, and standards.

Requirements

• Bachelor’s Degree in nursing, or equivalent.
• Active and unrestricted licensure as a Registered Nurse in Massachusetts.
• Three to five years of related work experience including state/federal regulatory agency.
• Three to five years clinical experience in utilization review, appeals, or case management within a healthcare or managed care setting.
• Previous experience in Home Care preferred.

Responsibilities

• Analyze appeal cases involving denied, modified, or terminated services.
• Review member medical records, prior authorization documentation, and internal appeal decisions.
• Ensure all relevant clinical and administrative documentation is complete and accurate.
• Create and review hearing packets.
• Prepare a clear and defensible case presentation aligned with MassHealth regulations and Fallon policies.
• Serve as the official representative of Fallon during Fair Hearings.
• Provide testimony and present the Fallon’s position to the hearing officer, including clinical rationale and policy justification.
• Respond to questions from the hearing officer and member or their representative.
• Submit additional documentation if requested during or after the hearing.
• Ensure all appeal activities comply with MassHealth Fair Hearing regulations (130 CMR 610.000).
• Adhere to required timelines, including submission of documentation and response deadlines.
• Maintain confidentiality and professionalism throughout the hearing process.
• Collaborate with internal departments (e.g., UM, PA, medical directors, legal, compliance) to gather supporting information.
• Communicate effectively with MassHealth staff, hearing officers, and member representatives.
• Coordinate pre-hearing resolution efforts when applicable.
• Support policy, procedure, workflow and performance improvement activities, as related to BOH decisions and trends, regulatory requirements and/or changes, and team case review outcomes.
• Administrate Fallon Health Standard and Expedited Appeals Processes as outlined in Member Handbook/Evidence of Coverage, and in compliance with applicable NCQA standards, CMS, MassHealth and other state or federal regulatory requirements.
• Work with Director and management team in developing and implementing specific work plans for improvements in department work processes.
• Serve in a senior capacity providing guidance, training, and/or assistance to staff regarding processing of BOH appeals.
• Commands overall understanding of Department goals and processes. Understands interdepartmental processes and relationships.
• Special projects as assigned by Director.

What This Job Offers

• Job Type: Full-time
• Education Level: Bachelor's degree