Medicare Appeals and Grievances Nurse

Mass General Brigham (Enterprise Services); Somerville (MA); Remote; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare provider is seeking a Clinical Appeals Review Specialist responsible for reviewing clinical and pharmacy appeals. This role requires an RN license and involves remote work with quarterly in-person meetings in Somerville. Ideal candidates have 3-5 years of experience in clinical appeals and excellent communication skills. The position offers a collaborative work environment and the need for on-call coverage on weekends.

Benefits

Remote role

Quarterly team meetings

Equal Opportunity Employer

Qualifications

• 3-5 years of experience in clinical appeals, grievances, or related healthcare services required.
• 2-3 years of clinical experience required.
• Experience with Medicare Advantage appeals preferred.

Responsibilities

• Review clinical/pharmacy appeal cases and provide recommendations.
• Maintain compliance with regulatory requirements.
• Provide recommendations on clinical/pharmacy appeal cases for medical director review.

Skills

Critical thinking

Analytical skills

Organizational skills

Effective communication

Tech aptitude

Education

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

Massachusetts Registered Nurse (RN) license

Tools

Microsoft Office products

Job description

Overview

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 weekends/holidays (currently every other weekend).

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

Education & Licenses

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

• 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

Working Conditions

• Remote role with quarterly in-person meetings at Assembly Row, Somerville; attendance is highly encouraged
• On-call coverage on weekends/holidays (currently every other weekend)

Mass General Brigham Incorporated is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. 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.