Medicare Appeals and Grievances Nurse

Massachusetts General Hospital; Somerville (MA); Remote; USD 62,000 - 91,000; Full time

Job summary

A major healthcare institution in Somerville seeks a Clinical Appeals and Grievance Coordinator (RN) to ensure compliance in clinical appeal reviews and collaborate with teams on complex cases. This remote role requires a Massachusetts RN license and 3-5 years of healthcare experience. Candidates should possess strong communication skills and attention to detail, with the ability to manage multiple cases effectively. Competitive pay and comprehensive benefits are offered.

Benefits

Comprehensive benefits

Career advancement opportunities

Competitive base pay

Qualifications

• Must have a Massachusetts Registered Nurse (RN) license.
• 3-5 years of experience in clinical appeals or grievances required.
• Strong preference for health plan experience.

Responsibilities

• Ensure clinical/pharmacy appeals and grievances are resolved timely.
• Directly interact with providers to obtain clinical information.
• Review clinical appeals and provide recommendations.

Skills

Communication skills

Attention to detail

Ability to manage multiple cases

Strong technology aptitude

Education

Bachelor's Degree in Healthcare Administration, Nursing, or related field

Job description

Overview

Mass General Brigham relies on a wide range of professionals to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We 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 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.

Responsibilities

• Essential Functions Clinical Appeals Review
  • In conjunction with other appeal team members, 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
• Action
  • Provide 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 to 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

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; strong technology aptitude; ability to work independently and in a team; excellent communication skills; meticulous attention to detail; ability to manage multiple cases and meet deadlines; ability to read and interpret clinical research and regulatory documents; ability to present information to various stakeholders

Perspective on Work

• Responsibilities and Qualifications reflect the required duties and candidate profile for this role.

Additional Job Details

• Working Conditions: Remote role with quarterly in-person meetings at Assembly Row, Somerville; on-call coverage on 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)
• Pay Range: $62,400.00 - $90,750.40/Annual
• Grade: 6

At 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. 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 Incorporated 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 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.