Medicare Appeals and Grievances Nurse

Mass General Brigham•Somerville, MA

12d•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 While a remote role, this team meets every quarter at the office at Assembly Row in Somerville and attendance is highly encouraged. This role would also require on-call coverage on the weekends/holidays (currently every other weekend). 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. The Clinical Appeals and Grievance Coordinator (RN) is an integral part of our Appeals and Grievance review process. Under the direction of the Director of Appeals and Grievances, this clinician will ensure clinical/pharmacy appeal cases reviews meet contractual, regulatory and business goals. As part of the Clinical Appeal process, the Clinical Appeals and Grievance Coordinator (RN) 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 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
Demonstrate Mass General Brigham Health Plan’s core brand principles of always listening, challenging conventions, and providing value.
Bring fresh ideas forward by listening to and collaborating with employees and the people we serve.
Strong aptitude for technology-based solutions.
Ability to inject energy, when and where it’s needed.
Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback.
Be accountable for delivering high-quality work.
Act with a clear sense of ownership.
Bring fresh ideas forward by actively listening to and working with employees and the people we serve.
Excellent critical thinking, analytical, and organizational skills
Proficient in Microsoft Office products
Proficient in internet research
Ability to work well both independently and in a team
Excellent oral and written communication skills
Meticulous attention to detail
Ability to influence others and persevere in situations
Ability to initiate administrative activities as necessary and institute quality control procedures.
Ability to manage multiple cases, meet deadlines, and adjust to changes in company policies, procedures, and priorities.
Ability to read, analyze and interpret clinical research, general business periodicals, professional journals, government regulations and legal documents.
Ability to effectively present information and respond to inquiries from employees, senior management, and regulatory agencies

Nice To Haves

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

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
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.
Provides recommendations on all clinical/pharmacy appeal cases for medical director review
Provider outreach as necessary to obtain additional clinical information
Work independently on cases while meeting obligatory turnaround times
Submission of appeal cases external vendors as required
Drafting appeal and grievance resolution correspondence prior to final review