Brigham and Women's Hospital-posted 3 months ago
Full-time
Remote • Somerville, MA
5,001-10,000 employees
Hospitals

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. The ideal candidate for this role will have Medicare Advantage appeals experience. Part of this role is building cases, gathering information to support an appeal, and making cases from beginning to end. The ideal candidate has experience building the IRE case file.

  • Ensure 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.
  • 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.
  • Other duties as assigned with or without accommodation.
  • Bachelor's Degree in Healthcare Administration, Nursing, or related field of study 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, with a strong preference for health plan experience.
  • At least 2-3 years of clinical experience required.
  • At least 3-5 years of Medicare Advantage appeals.
  • At least 5 years of experience working with members, providers, and internal staff on complex and sensitive requests for clinical services is highly preferred.
  • At least 5 years of experience working in multiple data systems is highly preferred.
  • Experience with multiple product lines, including Commercial, Exchange, Medicaid, and Medicare Advantage highly preferred.
  • Familiarity with InterQual Criteria.
  • Knowledge of Medicare national and local coverage determinations.
© 2024 Teal Labs, Inc
Privacy PolicyTerms of Service