<p>Site: Mass General Brigham Health Plan Holding Company, Inc.</p> <p>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.</p> <p>This is a part-time 20 hour/week role. While a remote role, this team meets every quarter at the office at Assembly Row in Somerville and attendance is highly encouraged</p> <p>Job Summary</p> <p>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.</p> <p>Essential Functions</p> <ul> <li>In conjunction with other appeal team members, ensures that clinical/pharmacy appeals and grievances are resolved timely to meet regulatory timeframes. </li><li>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. </li><li>Review clinical/pharmacy appeal cases and provide recommendations to the medical director team based on analysis of the clinical material. </li><li>Interact closely with pharmacy staff on pharmacy related reviews in preparation for physician review if needed </li><li>Identify cases that may require specialty review and expedite submission of cases to our contracted vendor (s) for this purpose </li><li>Analyze and complete written summaries on clinical cases. </li><li>Maintain compliance with all required turnaround times </li><li>Maintain compliance with all regulatory and NCQA requirements with regards to this important work </li></ul> <p>Qualifications</p> <p>Education</p> <ul> <li>Bachelor's Degree required </li></ul> <p>Licenses and Credentials</p> <ul> <li>Massachusetts Registered Nurse (RN) required </li></ul> <p>Experience</p> <ul> <li>At least 3-5 years of experience in clinical appeals, grievances, utilization review, or related healthcare services required </li><li>At least 2-3 years of clinical experience required </li></ul> <p>Preferred</p> <ul> <li>5 years of experience working with members, providers, and internal staff on complex and sensitive requests for clinical services </li><li>5 years of experience working in multiple data systems </li><li>Experience with multiple product lines, including Commercial, Exchange, Medicaid, and Medicare Advantage </li><li>Familiarity with InterQual Criteria </li><li>Knowledge of Medicare national and local coverage determinations </li></ul> <p>Knowledge, Skills, and Abilities</p> <ul> <li>Strong analytical and critical thinking skills. </li><li>Excellent verbal and written communication abilities. </li><li>Proficient in using electronic health records (EHR) and billing systems. </li><li>Detail-oriented with strong organizational skills. </li><li>Ability to handle sensitive information with confidentiality and professionalism. </li><li>Strong interpersonal skills to work effectively with various stakeholders. </li></ul> <p>Additional Job Details (if applicable)</p> <p>Working Conditions</p> <ul> <li>This is a part-time 20-hour/week role </li><li>While a remote role, this team meets every quarter at the office at Assembly Row in Somerville and attendance is highly encouraged. </li></ul> <p>Remote Type</p> <p>Remote</p> <p>Work Location</p> <p>399 Revolution Drive</p> <p>Scheduled Weekly Hours</p> <p>20</p> <p>Employee Type</p> <p>Regular</p> <p>Work Shift</p> <p>Day (United States of America)</p> <p>EEO Statement:</p> <p>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.</p> <p>Mass General Brigham Competency Framework</p> <p>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.</p>