Sr Nurse External Appeal Reviewer

Mass General Brigham•Somerville, MA

2d•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. The Senior Nurse Reviewer is responsible for the coordination, facilitation, and appeal of the clinical components of charge audits and forensic review findings. This includes audits conducted at Mass General Brigham (MGB) facilities in accordance with the MGB Charge Audit Policy and established departmental policies/procedures. The Senior Nurse Reviewer plays an important role in appealing challenges to charging policy and practice. The increased use of pre- and post-payer audits impacts MGB net revenue, to which the incumbent responds.

Requirements

Bachelor's Degree in Nursing required
Registered Nurse [RN - MA State License] - required
3+ years of experience in clinical nursing required
2+ years of experience in a quality assurance or clinical review role required
Strong appeal writing experience
Strong analytical skills with the ability to interpret clinical data and identify trends.
Excellent communication and interpersonal skills, with the ability to collaborate effectively with multidisciplinary teams.
Proficient in electronic health record (EHR) systems and clinical documentation tools.
Strong organizational skills and attention to detail.
Ability to provide constructive feedback and facilitate training for nursing staff.

Responsibilities

Coordinates the scheduling of audits with external third-party audit representatives/payors to initiate the audit process.
Prepares detailed packages for cases selected by audit representatives, including necessary documents needed to initiate the audit process.
Prepares audit responses and appeals for complex charge and forensic audits.
Documents, summarizes, and defends audit findings in a clear, concise, and effective manner to preserve MGB appeal rights.
Conducts post-audit research to support and defend cited charges by obtaining additional documentation.
Updates internal systems used for tracking and reporting findings, including but not limited to patient accounting systems, spreadsheets, and databases, to facilitate monthly management reporting.
Provides subject matter knowledge on various billing, coding, and clinical topics to the audit representatives and other key customers as needed.