Clinical Appeals and Grievances Nurse

Massachusetts General Hospital; Somerville (MA); Remote; USD 70,000 - 90,000; Full time

Job summary

Massachusetts General Hospital is seeking a Clinical Appeals and Grievance Coordinator (RN) to oversee the clinical appeals process. In this remote role with required on-site meetings, you will ensure timely resolution of claims while collaborating with medical and pharmacy teams. The ideal candidate will have a strong background in clinical appeals, excellent communication skills, and the ability to manage intricate cases. This position supports the mission of advancing patient care through effective clinical decision-making.

Qualifications

• Bachelor's Degree required.
• Massachusetts RN license required.
• 3-5 years of clinical appeals experience preferred.

Responsibilities

• Conduct clinical/pharmacy appeal reviews in compliance with regulations.
• Collaborate with providers and patients in the appeal process.
• Assist in drafting appeal resolution correspondence.

Skills

Critical Thinking

Analytical Skills

Communication

Organizational Skills

Technology Aptitude

Education

Bachelor's Degree in Healthcare Administration or Nursing

Tools

Microsoft Office

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.

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.

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 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.

Essential Functions Clinical Appeals Review
• 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.

Qualifications

Education:

• Bachelor's Degree in Healthcare Administration, Nursing, or related field of study required

Licenses and Certifications

• Massachusetts Registered Nurse (RN) license required

Work Experience

• 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

Preferred:

• 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

Skills/Competencies

• 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

Action

• 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

Organizational Relationships/Scope

• Reports directly to the Director, Appeals and Grievances and ensures the department goals set forth by the Director and Chief Medical Officer are met.
• Work collaboratively with others within Quality and Clinical and across all departments

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.
• This role requires on-call coverage on the weekends/holidays (currently every other weekend)

Remote Type

Remote

Work Location

399 Revolution Drive

Scheduled Weekly Hours

40

Employee Type

Regular

Work Shift

Day (United States of America)

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.