Key Facts

Remote From:

Full time

Mid-level (2-5 years)

English

Hard Skills

Utilization Management Malpractice Litigation Communicating With Patients Case Management Systems Industry Trend Analysis Clinical Informatics Billing Regulatory Compliance Quality Assessment Provider Network Management Cross-Functional Collaboration Clinical Documentation Electronic Health Record Applications Online Communication Patient Education And Counseling

Other Skills

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Client Confidentiality
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Non-Verbal Communication
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Teamwork
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Critical Thinking
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Organizational Skills
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Analytical Thinking
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Detail Oriented
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Social Skills

Roles & Responsibilities

Bachelor's Degree in Nursing
Massachusetts Registered Nurse (RN) License
At least 3-5 years of experience in clinical appeals, grievances, utilization review, or related healthcare services
At least 2-3 years of clinical experience

Requirements:

Ensure clinical/pharmacy appeals and grievances are resolved timely to meet regulatory timeframes
Directly interact with providers and their staff to obtain additional clinical information as well as with members or advocates to understand the full intent of the appeal or clinical grievance
Review clinical/pharmacy appeal cases and provide recommendations to the medical director team based on analysis of the clinical material
Tracks and monitors the status of appeals and grievances, ensuring timely resolution and follow-up

Brigham and Women's Hospital

About Brigham and Women's Hospital

Boston's Brigham and Women's Hospital (BWH) is an international leader in virtually every area of medicine and has been the site of pioneering breakthroughs that have improved lives around the world. A major teaching hospital of Harvard Medical School, BWH has a legacy of excellence that continues to grow. With two outstanding hospitals, over 150 outpatient practices, and over 1,200 physicians, we serve patients from New England, throughout the United States, and from 120 countries around the world. The BWH name is a reflection of our history. In 1980 three of Boston’s oldest and most prestigious Harvard Medical School teaching hospitals - the Peter Bent Brigham Hospital, the Robert Breck Brigham Hospital, and the Boston Hospital for Women – merged to form Brigham and Women’s Hospital. As a national leader in improving health care quality and safety, we have helped to develop some of the industry’s best practices including computerized physician order entry (CPOE) to prevent medication errors. The CPOE is now a nationally-accepted safety practice. The BWH Biomedical Research Institute (BRI) is one of the most powerful biomedical research institutes in the world and the second largest recipient of National Institutes of Health (NIH) funding among independent hospitals in the United States. BWH has long had great success in research as measured by the number of important discoveries made, the size and scope of its research portfolio and the volume of publications annually. BWH is a training ground for physicians, nurses, and allied health professionals. We have 1,100 trainees in over 140 of the most sought after training programs in the world, and also host Harvard Medical School students in rotations throughout our programs. As our global health services expand, our clinical trainees have rich opportunities to contribute and learn in challenging environments around the world. Brigham and Women's Hospital is an EEO, AA, VEVRAA Employer.

Founded: 2018

Company size: 10001

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Job description

Site: Mass General Brigham Health Plan Holding Company, Inc.

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.

Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills.

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

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. The 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

Essential Functions
-In conjunction with other appeal team members, ensures that clinical/pharmacy appeals and grievances are resolved timely to meet regulatory timeframes.
-Directly interact with providers and their staff to obtain additional clinical information as well as with members or their advocates to understand the full intent of the appeal or clinical grievance.
-Review clinical/pharmacy appeal cases and provide recommendations to the medical director team based on analysis of the clinical material.
-Reviews and analyzes clinical appeals and grievances to determine validity and appropriate course of action. Completes written summaries on clinical cases.
-Tracks and monitors the status of appeals and grievances, ensuring timely resolution and follow-up.
-Identifies trends and patterns in appeals and grievances to inform quality improvement initiatives.
-Coordinates communication between patients, healthcare providers, and insurance companies regarding appeals and grievances.
-Educates staff and patients about the appeals and grievances process to enhance understanding and compliance.
-Participates in interdisciplinary meetings to discuss complex cases and recommend solutions.

Qualifications

Education

Bachelor's Degree in Nursing required

Licenses and Credentials

Massachusetts Registered Nurse (RN License) required

Experience

At least 3-5 years of experience in clinical appeals, grievances, utilization review, or related healthcare services required
At least 2-3 years of clinical experience required

Knowledge, Skills and Abilities

Strong analytical and critical thinking skills.
Excellent verbal and written communication abilities.
Proficient in using electronic health records (EHR) and billing systems.
Detail-oriented with strong organizational skills.
Ability to handle sensitive information with confidentiality and professionalism.
Strong interpersonal skills to work effectively with various stakeholders.

Additional Job Details (if applicable)

Working Conditions

While a remote role, this team meets every quarter at the office at Assembly Row in Somerville and attendance is highly encouraged.

Remote Type

Remote

Work Location

399 Revolution Drive

Scheduled Weekly Hours

Employee Type

Regular

Work Shift

Day (United States of America)

Pay Range

$63,648.00 - $90,750.40/Annual

Grade

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

EEO Statement:

8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

Mass General Brigham Competency Framework

At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.

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