Medicare Appeals and Grievances Nurse

You may choose to display a cookie banner on the external site. You must specify the message in the cookie banner and may add a link to a relevant policy. If you are unfamiliar with these requirements, please seek the advice of legal counsel. )* At least 3-5 years of experience in clinical appeals, grievances, utilization review, or related healthcare services required, with a strong preference for health plan experience* At least 2-3 years of clinical experience required* At least 3-5 years of Medicare Advantage appeals* At least 5 years of experience working with members, providers, and internal staff on complex and sensitive requests for clinical services is highly preferred* At least 5 years of experience working in multiple data systems is highly preferred* Experience with multiple product lines, including Commercial, Exchange, Medicaid, and Medicare Advantage highly preferred* Familiarity with InterQual Criteria* Knowledge of Medicare national and local coverage determinations* Demonstrate Mass General Brigham Health Plan’s core brand principles of always listening, challenging conventions, and providing value.* Bring fresh ideas forward by listening to and collaborating with employees and the people we serve.* Strong aptitude for technology-based solutions.* Ability to inject energy, when and where it’s needed.* Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback.* Be accountable for delivering high-quality work. Act with a clear sense of ownership.* Bring fresh ideas forward by actively listening to and working with employees and the people we serve.* Excellent critical thinking, analytical, and organizational skills* Proficient in Microsoft Office products* Proficient in internet research* Ability to work well both independently and in a team* Excellent oral and written communication skills* Meticulous attention to detail* Ability to influence others and persevere in situations* Ability to initiate administrative activities as necessary and institute quality control procedures.* Ability to manage multiple cases, meet deadlines, and adjust to changes in company policies, procedures, and priorities.* Ability to read, analyze and interpret clinical research, general business periodicals, professional journals, government regulations and legal documents.* Ability to effectively present information and respond to inquiries from employees, senior management, and regulatory agencies* While a remote role, this team meets every quarter at the office at Assembly Row in Somerville and attendance is highly encouraged.* This role requires on-call coverage on the weekends/holidays (currently every other weekend)Combat disease. Hold a hand. Help people. Impact the world.Mass General Brigham is a passionate, welcoming community where minds meet caring hearts.Our history includes New England hospitals founded over 200 years ago, some of the first and most prestigious hospitals in the world.Built on the legacy of two leading academic medical centers, we’re more than a system—we’re leaders in the practice of medicine. Mass General Brigham is committed to serving the community.We are dedicated to enhancing patient care, teaching and research, and taking a leadership role as an integrated health care system.We recognize that increasing value and continuously improving quality are essential to maintaining excellence. #J-18808-Ljbffr