What are the responsibilities and job description for the Clinical Appeal and Grievance Nurse position at Mass General Brigham Health Plan?
Education
Bachelor's 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.
Working Conditions
While a remote role, this team meets every quarter at the office at Assembly Row in Somerville and attendance is highly encouraged.
Mass General Brigham Health Plan Holding Company, Inc. 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.
Our promise as a people-first organization starts with our employees. AllWays Health Partners is committed to diversity, equity, and inclusion in our workforce, internal culture, and investments. As an equal opportunity employer, AllWays Health Partners recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives, and backgrounds.