Massachusetts Licensed Clinical Nurse
Job Summary
To support the Appeals and Grievance review process, the full-time Massachusetts Licensed Clinical Nurse will ensure timely resolution of clinical and pharmacy appeal cases, collaborating with various healthcare teams in a remote work environment.
Key responsibilities
- Ensure timely resolution of clinical/pharmacy appeals and grievances in compliance with regulatory timeframes
- Interact with providers and members to gather clinical information and understand the intent of appeals or grievances
- Review appeal cases and provide recommendations to the medical director based on clinical analysis
Required qualifications
- Bachelor's Degree required
- Massachusetts Registered Nurse (RN) license required
- 3-5 years of experience in clinical appeals, grievances, or utilization review required
- 2-3 years of clinical experience required
- Strong analytical and critical thinking skills
Complete Job Description
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