Clinical Appeal And Grievance Nurse

Brigham and Women's Faulkner Hospital

Somerville, MA, USA
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 ensures clinical and pharmacy appeal cases meet contractual, regulatory, and business goals within Mass General Brigham Health Plan

Job Summary

  • The role ensures clinical and pharmacy appeal cases meet contractual, regulatory, and business goals within Mass General Brigham Health Plan.
  • Employees will collaborate with medical directors, pharmacy staff, and providers to resolve complex clinical issues across the appeal landscape.
  • The position offers a competitive salary range of $63,648.00 to $90,750.40 annually along with flexible work options and comprehensive benefits.

Matching Summary

The role ensures clinical and pharmacy appeal cases meet contractual, regulatory, and business goals within Mass General Brigham Health Plan.

Salary

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

Skills & Requirements

Must-have

  • Massachusetts Registered Nurse license required
  • 3-5 years clinical appeals experience
  • 2-3 years direct clinical experience
  • Regulatory timeframe compliance
  • Provider and member interaction

Nice-to-have

  • Experience with InterQual Criteria
  • Knowledge of Medicare coverage determinations
  • Familiarity with multiple data systems
  • Strong analytical and critical thinking skills
  • Experience with Commercial and Medicaid products

Key Requirements

  • Bachelor's Degree required
  • Massachusetts RN License required
  • 3-5 years in clinical appeals or utilization review
  • 2-3 years of clinical experience required

Work Rights

Not specified

Tailored Resume

Cover Letter