Clinical Appeal and Grievance Nurse

Essential Functions

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• In conjunction with other appeal team members, ensures that clinical/pharmacy appeals and grievances are resolved in a timely manner to meet regulatory time frames.
• 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.

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 Inter Qual 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.

• 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 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.

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.