Partners HealthCare
Clinical Appeals and Grievances Nurse
Partners HealthCare, Boston, Massachusetts, us, 02298
While a remote role, this team meets every other month at the office at Assembly Row in Somerville and attendance is highly encouraged. This role would also require on-call coverage on the weekends/holidays (currently every 4-6 weeks).
The Clinical Appeals and Grievance Coordinator (RN) is an integral part of our Appeals and Grievance review process. Under the direction of the Director of Appeals and Grievances, this clinician will ensure clinical/pharmacy appeal cases reviews meet contractual, regulatory and business goals.
As part of the Clinical Appeal process, the Clinical Appeals and Grievance Coordinator (RN) 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
Clinical Appeals Review• 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• Interact closely with pharmacy staff on pharmacy related reviews in preparation for physician review if needed• Identify cases that may require specialty review and expedite submission of cases to our contracted vendor (s) for this purpose• Analyze and complete written summaries on clinical cases.• Maintain compliance with all required turnaround times• Maintain compliance with all regulatory and NCQA requirements with regards to this important work
• Other duties as assigned with or without accommodation.
Working Conditions and Physical Effort• This position is currently remote
The Clinical Appeals and Grievance Coordinator (RN) is an integral part of our Appeals and Grievance review process. Under the direction of the Director of Appeals and Grievances, this clinician will ensure clinical/pharmacy appeal cases reviews meet contractual, regulatory and business goals.
As part of the Clinical Appeal process, the Clinical Appeals and Grievance Coordinator (RN) 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
Clinical Appeals Review• 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• Interact closely with pharmacy staff on pharmacy related reviews in preparation for physician review if needed• Identify cases that may require specialty review and expedite submission of cases to our contracted vendor (s) for this purpose• Analyze and complete written summaries on clinical cases.• Maintain compliance with all required turnaround times• Maintain compliance with all regulatory and NCQA requirements with regards to this important work
• Other duties as assigned with or without accommodation.
Working Conditions and Physical Effort• This position is currently remote