Sr Nurse External Appeal Reviewer
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Job Location:
Somerville, NJ - USA
Monthly Salary:
$ 79560 - 115720
Posted on:
3 days 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 Senior Nurse Reviewer is responsible for the coordination facilitation and appeal of the clinical components of charge audits and forensic review findings. This includes audits conducted at Mass General Brigham (MGB) facilities in accordance with the MGB Charge Audit Policy and established departmental policies/procedures. The Senior Nurse Reviewer plays an important role in appealing challenges to charging policy and practice. The increased use of pre- and post-payer audits impacts MGB net revenue to which the incumbent responds.Essential Functions
-Coordinates the scheduling of audits with external third-party audit representatives/payors to initiate the audit process.
-Prepares detailed packages for cases selected by audit representatives including necessary documents needed to initiate the audit process.
-Prepares audit responses and appeals for complex charge and forensic audits.
-Documents summarizes and defends audit findings in a clear concise and effective manner to preserve MGB appeal rights.
-Conducts post-audit research to support and defend cited charges by obtaining additional documentation.
-Updates internal systems used for tracking and reporting findings including but not limited to patient accounting systems spreadsheets and databases to facilitate monthly management reporting.
-Provides subject matter knowledge on various billing coding and clinical topics to the audit representatives and other key customers as needed.
Qualifications
Bachelors Degree in Nursing required
Registered Nurse RN - MA State License - required
3 years of experience in clinical nursing required
2 years of experience in a quality assurance or clinical review role required
Skill for Success
It is essential that the candidate possesses strong appeal writing experience as this skill is critical for successfully supporting and defending clinical charge audit findings during the appeals process.
Strong analytical skills with the ability to interpret clinical data and identify trends.
Excellent communication and interpersonal skills with the ability to collaborate effectively with multidisciplinary teams.
Proficient in electronic health record (EHR) systems and clinical documentation tools.
Strong organizational skills and attention to detail.
Ability to provide constructive feedback and facilitate training for nursing staff.
Working schedule:
- Remote M-F eastern standard business hours. Requires a quiet secure HIPAA-compliant working station
Additional Job Details (if applicable)
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay Range
$79560.00 - $115720.80/AnnualGrade
7EEO 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:
Senior IC
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.
