Medicare Appeals and Grievances Nurse

Mass General Brigham Health Plan
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Aug 06, 2025
While a remote role, this team meets every quarter at the office at Assembly Row in Somerville and attendance is highly encouraged. This role would also require on-call coverage on the weekends/holidays (currently every other weekend). The ideal candidate for this role will have Medicare Advantage appeals experience. Part of this role is building cases, gathering information to support an appeal, and making cases from beginning to end. The ideal candidate has experience building the IRE case file. 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 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. Education: Bachelor's Degree in Healthcare Administration, Nursing, or related field of study required Licenses and Certifications Massachusetts Registered Nurse (RN) license required Work Experience At least 3-5 years of experience in clinical appeals, grievances, utilization review, or related healthcare services required, with a strong preference for health plan experience At least 2-3 years of clinical experience required Preferred: At least 3-5 years of Medicare Advantage appeals At least 5 years of experience working with members, providers, and internal staff on complex and sensitive requests for clinical services is highly preferred At least 5 years of experience working in multiple data systems is highly preferred Experience with multiple product lines, including Commercial, Exchange, Medicaid, and Medicare Advantage highly preferred Familiarity with InterQual Criteria Knowledge of Medicare national and local coverage determinations Skills/Competencies Demonstrate Mass General Brigham Health Plan'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. 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 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 external vendors as required Drafting appeal and grievance resolution correspondence prior to final review 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 Working Conditions: While a remote role, this team meets every quarter at the office at Assembly Row in Somerville and attendance is highly encouraged. This role requires on-call coverage on the weekends/holidays (currently every other weekend) 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.