The role ensures clinical and pharmacy appeal cases meet contractual, regulatory, and business goals within a leading integrated healthcare system
Job Summary
The role ensures clinical and pharmacy appeal cases meet contractual, regulatory, and business goals within a leading integrated healthcare system.
Employees collaborate with medical directors, pharmacy teams, and providers to resolve complex clinical issues and ensure timely grievance resolution.
The position offers competitive salaries, flexible work options, and career growth opportunities within a supportive, not-for-profit organization.
Matching Summary
The role ensures clinical and pharmacy appeal cases meet contractual, regulatory, and business goals within a leading integrated healthcare system.
Salary
Base: $63,648.00 - $90,750.40 annually; Bonus/Equity: Not specified; Benefits: Comprehensive package including flexible work options and career advancement
Skills & Requirements
Must-have
Massachusetts Registered Nurse license required
3-5 years clinical appeals experience
2-3 years direct clinical experience
Electronic health records proficiency
Regulatory timeframe adherence
Nice-to-have
Strong analytical and critical thinking skills
Excellent verbal and written communication
Interdisciplinary meeting participation
Patient advocacy and education focus
Trend identification for quality initiatives
Key Requirements
Bachelor's Degree in Nursing
Massachusetts RN License
3-5 years appeals/grievances experience
2-3 years clinical experience
Remote work capability with quarterly office attendance