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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.
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Our work centers on creating an exceptional member experience ā 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 welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills.
We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more.
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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
ā¢ In conjunction with other appeal team members, ensures that clinical/pharmacy appeals and grievances are resolved in a timely manner to meet regulatory timeframes.
ā¢ 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.
ā¢ Review clinical/pharmacy appeal cases and provide recommendations to the medical director team based on analysis of the clinical material.
ā¢ Interact closely with pharmacy staff on pharmacy-related reviews in preparation for physician review if needed
ā¢ Identify cases that may require specialty review and expedite submission of cases to our contracted vendor (s) for this purpose
ā¢ Analyze and complete written summaries on clinical cases.
ā¢ Maintain compliance with all required turnaround times
ā¢ Maintain compliance with all regulatory and NCQA requirements with regards to this important work
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Qualifications
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 AdvantageĀ
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.
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Additional Job Details (if applicable)
Working Conditions
While a remote role, this team meets every quarter at the office at Assembly Row in Somerville and attendance is highly encouraged.
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Remote Type
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Work Location
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Scheduled Weekly Hours
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Employee Type
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Work Shift
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Pay Range
$63,648.00 - $90,750.40/Annual
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Grade
6
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EEO Statement:
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Mass General Brigham Competency Framework
At Mass General Brigham, our competency framework defines what effective leadership ālooks likeā 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.
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