Clinical Appeals And Grievances Nurse

While a remote role, this team meets every other month at the office at Assembly Row in Somerville and attendance is highly encouraged.

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world's leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.

Our work centers on creating an exceptional member experience - a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a consciously inclusive environment where diversity is celebrated.

We are pleased to offer competitive salaries, and a benefits package with flexible work options, career growth opportunities, and much more.

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 the 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.

Working Conditions and Physical Effort

• This position is currently remote

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 to external vendors as required

• Drafting appeal and grievance resolution correspondence prior to final review

Knowledge and Education:

Required:

• Bachelor's Degree
• RN degree with Massachusetts License

Experience:

Required:

• Minimum of 2 years of clinical experience

• Minimum of 3 years utilization review and/or appeals and grievance experience either with a health plan or health care facility

• Minimum of 5 years' experience working with members, providers and internal staff on complex and sensitive requests for clinical services

• Minimum of 5 years' experience working in multiple data systems

• Experience with multiple product lines including Commercial, Exchange, Medicaid, and Medicare Advantage

Preferred:

• Familiarity with InterQual Criteria

• Knowledge of Medicare national and local coverage determinations

• Demonstrate Mass General Brigham'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.

• Respect the talent and unique contribution of every individual and treat all people in a fair and equitable manner.

• 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

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