Appeals and Grievances Nurse

Mass General Brigham; Somerville (MA); Remote; USD 62,000 - 91,000; Full time

Job summary

A leading healthcare organization is seeking a Clinical Appeals Specialist to manage the appeals and grievance review process. This remote position requires collaboration with clinical teams and strong analytical skills. Candidates must hold a Bachelor's Degree in Nursing and a Massachusetts RN License, along with experience in clinical appeals. The role offers a comprehensive benefits package and a salary range of $62,400.00 - $90,750.40 annually.

Benefits

Comprehensive benefits

Career advancement opportunities

Recognition programs

Qualifications

• Bachelor's Degree in Nursing required.
• Massachusetts Registered Nurse (RN License) required.
• 3-5 years of experience in clinical appeals, grievances, or utilization review required.
• 2-3 years of clinical experience required.

Responsibilities

• Ensure clinical/pharmacy appeals and grievances are resolved timely.
• Interact with providers and members to gather clinical information.
• Review clinical/pharmacy appeal cases and provide recommendations.
• Track and monitor the status of appeals and grievances.

Skills

Analytical skills

Verbal communication

Written communication

Organizational skills

Interpersonal skills

Education

Bachelor's Degree in Nursing

Tools

Electronic Health Records (EHR)

Billing systems

Job description

Site: Mass General Brigham Health Plan Holding Company, Inc.

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

Essential Functions
-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.
-Reviews and analyzes clinical appeals and grievances to determine validity and appropriate course of action. Completes written summaries on clinical cases.
-Tracks and monitors the status of appeals and grievances, ensuring timely resolution and follow-up.
-Identifies trends and patterns in appeals and grievances to inform quality improvement initiatives.
-Coordinates communication between patients, healthcare providers, and insurance companies regarding appeals and grievances.
-Educates staff and patients about the appeals and grievances process to enhance understanding and compliance.
-Participates in interdisciplinary meetings to discuss complex cases and recommend solutions.

Qualifications

Education

• Bachelor's Degree in Nursing required

Licenses and Credentials

• Massachusetts Registered Nurse (RN License) required

Experience

• 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

Knowledge, Skills and Abilities

• 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.

Additional Job Details (if applicable)

Working Conditions

• While a remote role, this team meets every quarter at the office at Assembly Row in Somerville and attendance is highly encouraged.

Remote Type

Remote

Work Location

399 Revolution Drive

Scheduled Weekly Hours

40

Employee Type

Regular

Work Shift

Day (United States of America)

Pay Range

$62,400.00 - $90,750.40/Annual

Grade

6At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

EEO Statement:

Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642. Mass General Brigham Competency Framework

At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.