Clinical Appeal And Grievance Nurse

Mass General Brigham Health Plan Holding Company, Inc.

Somerville, MA, US
Base: $63,648.00 - $90,750.40 annually; bonus/equi...
Fully remote
Massachusetts registered nurse license required
3-5 years clinical appeals experience
2-3 years direct clinical experience
The role ensures clinical and pharmacy appeal cases are resolved timely to meet strict regulatory timeframes

Job Summary

  • The role ensures clinical and pharmacy appeal cases are resolved timely to meet strict regulatory timeframes.
  • Employees collaborate with medical directors, pharmacy staff, and providers to resolve complex clinical issues across the appeal landscape.
  • The position offers competitive salaries, flexible work options, and career growth opportunities within a supportive healthcare environment.

Matching Summary

The role ensures clinical and pharmacy appeal cases are resolved timely to meet strict regulatory timeframes.

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
  • Regulatory timeframe adherence
  • Provider and member interaction

Nice-to-have

  • Experience with complex sensitive requests
  • Familiarity with InterQual criteria
  • Knowledge of Medicare coverage determinations
  • Multi-product line experience
  • Strong analytical critical thinking skills

Key Requirements

  • Bachelor's Degree required
  • Massachusetts RN license mandatory
  • 3-5 years appeals or utilization review experience
  • 2-3 years clinical experience required

Work Rights

Not specified

Tailored Resume

Cover Letter