Clinical Appeal And Grievance Nurse

621

Somerville, MA, United States
Base: $63,648.00 - $90,750.40/annual; bonus/equity...
Fully remote
Massachusetts registered nurse license required
3-5 years clinical appeals experience
2-3 years direct clinical experience
The role is an integral part of the Appeals and Grievance review process ensuring clinical cases meet contractual and regulatory goals

Job Summary

  • The role is an integral part of the Appeals and Grievance review process ensuring clinical cases meet contractual and regulatory goals.
  • Employees collaborate with pharmacy teams and medical directors to resolve complex clinical issues across the appeal landscape.
  • The position offers competitive salaries, flexible work options, and career growth opportunities within a welcoming healthcare environment.

Matching Summary

The role is an integral part of the Appeals and Grievance review process ensuring clinical cases meet contractual and regulatory goals.

Salary

Base: $63,648.00 - $90,750.40/Annual; Bonus/Equity: Not specified; Benefits: Comprehensive benefits package with flexible work options

Skills & Requirements

Must-have

  • Massachusetts Registered Nurse license required
  • 3-5 years clinical appeals experience
  • 2-3 years direct clinical experience
  • Review clinical appeal cases for medical directors
  • Interact with providers and members on appeals

Nice-to-have

  • Experience with InterQual criteria knowledge
  • Familiarity with Medicare coverage determinations
  • Strong analytical and critical thinking skills
  • Proficient in electronic health records systems
  • Experience with multiple product lines including Medicaid

Key Requirements

  • Bachelor's Degree required
  • Massachusetts Registered Nurse (RN) license
  • 3-5 years experience in clinical appeals or utilization review
  • 2-3 years clinical experience required

Work Rights

Not specified

Tailored Resume

Cover Letter