[Hiring] Senior Nurse External Appeal Reviewer @Mass General Brigham
Role Description The Senior Nurse Reviewer is responsible for the coordination, facilitation, and appeal of the clinical components of charge audits and forensic review findings. This includes audits conducted at Mass General Brigham (MGB) facilities in accordance with the MGB Charge Audit Policy and established departmental policies/procedures. The Senior Nurse Reviewer plays an important role in appealing challenges to charging policy and practice. The increased use of pre- and post-payer audits impacts MGB net revenue, to which the incumbent responds.
- Coordinates the scheduling of audits with external third-party audit representatives/payors to initiate the audit process.
- Prepares detailed packages for cases selected by audit representatives, including necessary documents needed to initiate the audit process.
- Prepares audit responses and appeals for complex charge and forensic audits.
- Documents, summarizes, and defends audit findings in a clear, concise, and effective manner to preserve MGB appeal rights.
- Conducts post-audit research to support and defend cited charges by obtaining additional documentation.
- Updates internal systems used for tracking and reporting findings, including but not limited to patient accounting systems, spreadsheets, and databases, to facilitate monthly management reporting.
- Provides subject matter knowledge on various billing, coding, and clinical topics to the audit representatives and other key customers as needed.
Qualifications
- Bachelor's Degree in Nursing required
- Registered Nurse [RN - MA State License] - required
- 3+ years of experience in clinical nursing required
- 2+ years of experience in a quality assurance or clinical review role required
Requirements
- Strong appeal writing experience, critical for successfully supporting and defending clinical charge audit findings during the appeals process.
- Strong analytical skills with the ability to interpret clinical data and identify trends.
- Excellent communication and interpersonal skills, with the ability to collaborate effectively with multidisciplinary teams.
- Proficient in electronic health record (EHR) systems and clinical documentation tools.
- Strong organizational skills and attention to detail.
- Ability to provide constructive feedback and facilitate training for nursing staff.
Benefits
- Competitive base pay
- Comprehensive benefits
- Career advancement opportunities
- Differentials, premiums, and bonuses as applicable
- Recognition programs designed to celebrate contributions and support professional growth
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