Clinical Appeal And Grievance Nurse

Mass. Eye And Ear

Somerville, MA, United States
Base: $63,648.00 - $90,750.40/annual; bonus/equity...
Fully remote
Clinical/pharmacy appeal case reviews
Resolve clinical issues
Interact with providers and members
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

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.
  • This 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.
  • We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more.

Matching 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.

Salary

Base: $63,648.00 - $90,750.40/Annual; Bonus/Equity: Not specified; Benefits: comprehensive benefits package

Skills & Requirements

Must-have

  • Clinical/pharmacy appeal case reviews
  • Resolve clinical issues
  • Interact with providers and members
  • Analyze clinical material
  • Maintain compliance with turnaround times
  • NCQA requirements

Nice-to-have

  • Exceptional member experience
  • Groundbreaking medical discoveries
  • Welcoming and supportive environment
  • Unique and varied backgrounds

Key Requirements

  • Bachelor's Degree required
  • Massachusetts Registered Nurse (RN) required
  • 3-5 years clinical appeals experience
  • 2-3 years clinical experience
  • Proficient in EHR and billing systems

Work Rights

Not specified

Tailored Resume

Cover Letter