Clinical Appeal and Grievance Nurse
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Job Location:
Somerville, NJ - USA
Monthly Salary:
$ 62400 - 90750
Posted on:
15 hours ago
Vacancies:
1 Vacancy
Job Summary
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 in a timely manner 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
Qualifications
Education
Bachelors Degree required
Licenses and Credentials
Massachusetts Registered Nurse (RN) 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
Preferred
5 years of experience working with members providers and internal staff on complex and sensitive requests for clinical services
5 years of experience working in multiple data systems
Experience with multiple product lines including Commercial Exchange Medicaid and Medicare Advantage
Familiarity with InterQual Criteria
Knowledge of Medicare national and local coverage determinations
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)
While a remote role this team meets every quarter at the office at Assembly Row in Somerville and attendance is highly encouraged.
The typical schedule for this role is Monday through Friday role with a schedule of 8:30 to 5 PM EDT
This role includes an on-call component where you would be on-call on weekends roughly every 6 weeks
Remote Type
Work Location
Pay Range
$62400.00 - $90750.40/AnnualGrade
6EEO Statement:
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.
Required Experience:
IC
Key Skills
- EMR Systems
- Hospital Experience
- Acute Care
- ICU Experience
- Dermal Fillers
- Experience Administering Injections
- Home Care
- Nursing
- Botox Experience
- Critical Care Experience
- Medication Administration
- Tube Feeding
About Company
Patients at Mass General have access to a vast network of physicians, nearly all of whom are Harvard Medical School faculty and many of whom are leaders within their fields.
