Clinical Appeal and Grievance Nurse

We need to output HTML fragment with sections: About the role? The posting includes a job summary, essential functions, qualifications, additional job details (working conditions, schedule, pay range). We need headings: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. Use

for each heading only if there is real specific content. We must not repeat job title as heading. Must preserve all substantive info. Remove boilerplate like EEO, competency framework, etc. Also remove navigation, cookie, legal, duplicated lines, application instructions. We need to decide which sections to include. Content: - Job Summary: description of role, mission, etc. Could go under "About the role". That's appropriate. - Essential Functions: list of duties. That's "Responsibilities". Use

• . - Qualifications: Education, Licenses and Credentials, Experience (required and preferred). That's "Qualifications". Could also separate "Requirements" vs "Qualifications"? The instruction says use headings: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. So we need to map. We have "Education Bachelor's Degree required", "Licenses and Credentials Massachusetts Registered Nurse (RN) required", "Experience At least 3-5 years of experience in clinical appeals, grievances, utilization review, or related healthcare services required At least 2-3 years of clinical experience required Preferred 5 years of experience working with members, providers, and internal staff on complex and sensitive requests for clinical services 5 years of experience working in multiple data systems Experience with multiple product lines, including Commercial, Exchange, Medicaid, and Medicare Advantage Familiarity with InterQual Criteria Knowledge of Medicare national and local coverage determinations". Also "Knowledge, Skills, And Abilities" list: Strong analytical and critical thinking skills, Excellent verbal and written communication abilities, Proficient in using electronic health records (EHR) and billing systems, Detail-oriented with strong organizational skills, Ability to handle sensitive information with confidentiality and professionalism, Strong interpersonal skills to work effectively with various stakeholders. Thus we have qualifications (education, license, experience) and skills (knowledge, skills, abilities). So we can put education/license/experience under "Qualifications" and the KSAs under "Skills". Or we could put experience under "Requirements". But we have both headings: Requirements and Qualifications. Usually Requirements could be mandatory qualifications; Qualifications could be preferred? But we need to follow instruction: include a section only when posting has real specific content. We have content for both. We could treat "Requirements" as mandatory: Education, License, Experience (minimum). And "Qualifications" as preferred qualifications/experience. Or we could combine. Let's decide: - Requirements: Education Bachelor's Degree required; Massachusetts Registered Nurse (RN) required; At least 3-5 years of experience in clinical appeals, grievances, utilization review, or related healthcare services required; At least 2-3 years of clinical experience required. - Qualifications (Preferred): Preferred 5 years of experience working with members, providers, and internal staff on complex and sensitive requests for clinical services; 5 years of experience working in multiple data systems; Experience with multiple product lines, including Commercial, Exchange, Medicaid, and Medicare Advantage; Familiarity with InterQual Criteria; Knowledge of Medicare national and local coverage determinations. - Skills: Knowledge, Skills, And Abilities list. - Benefits: The posting mentions "competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more." Also later: "In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs". So we have benefits info: flexible work options, career growth opportunities, comprehensive benefits, career advancement opportunities, differentials, premiums, bonuses, recognition programs. We'll include that under Benefits. - Pay: Pay Range $63,648.00 - $92,570.40/Annual Grade 6. Also mention base pay info. So we include Pay. - Schedule: Working Conditions: This is a remote role with occasional onsite team meetings in Somerville, MA. Monday through Friday, eastern business hours required. Remote workdays require a stable, secure, quiet, and HIPAA-compliant workspace. This will be confirmed via Microsoft Teams video for all employees. Remote Type Remote Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America). So schedule: Monday-Friday, eastern business hours, 40 hours/week, day shift. We'll include under Schedule. - About the role: Job Summary paragraph(s). We'll combine. We must not include boilerplate: EEO statement, competency framework, etc. Also remove "Additional Job Details (if Applicable)" heading but we can keep its content under appropriate sections. We must not repeat job title as heading. No Job ID/requisition numbers. We must output only HTML fragment, no /, no markdown fences. Let's craft. Structure:

  About the role

  ... job summary ...

  Responsibilities

  • ... essential functions ...

  Requirements

  • ... mandatory qualifications ...

  Qualifications

  • ... preferred qualifications ...

  Skills

  • ... knowledge, skills, abilities ...

  Benefits

  • ... benefits ...

  Pay

  Pay range: $63,648.00 - $92,570.40 per annual (Grade 6). Base pay determined based on skills, experience, education, certifications, etc.

  Schedule

  Monday–Friday, eastern business hours; 40 hours per week; day shift. Remote role with occasional onsite team meetings in Somerville, MA; requires a stable, secure, quiet, HIPAA‑compliant workspace.

  We need to ensure we preserve all substantive info. Let's extract exact phrasing. Job Summary: "Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage. Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills. We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more. 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." We can keep that as About the role. Essential Functions list: - In conjunction with other appeal team members, ensures that clinical/pharmacy appeals and grievances are resolved in a timely manner 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 We'll put each as
• . Requirements (mandatory): - Bachelor's Degree required - Massachusetts Registered Nurse (RN) required - At least 3-5 years of experience in clinical appeals, grievances, utilization review, or related healthcare services required - At least 2-3 years of clinical experience required Qualifications (preferred): - Preferred 5 years of experience working with members, providers, and internal staff on complex and sensitive requests for clinical services - 5 years of experience working in multiple data systems - Experience with multiple product lines, including Commercial, Exchange, Medicaid, and Medicare Advantage - Familiarity with InterQual Criteria - Knowledge of Medicare national and local coverage determinations Skills: - Strong analytical and critical thinking skills. - Excellent verbal and written communication abilities. - Proficient in using electronic health records (EHR) and billing systems. - Detail-oriented with strong organizational skills. - Ability to handle sensitive information with confidentiality and professionalism. - Strong interpersonal skills to work effectively with various stakeholders. Benefits: - Competitive salaries - Benefits package with flexible work options - Career growth opportunities - Comprehensive benefits - Career advancement opportunities - Differentials, premiums and bonuses as applicable - Recognition programs We could combine some. Pay: - Pay Range $63,648.00 - $92,570.40/Annual Grade 6 - Base pay determined based on skills, relevant experience, education, certifications and other essential factors. Schedule: - Remote role with occasional onsite team meetings in Somerville, MA. - Monday through Friday, eastern business hours required. - Remote workdays require a stable, secure, quiet, and HIPAA‑compliant workspace (confirmed via Microsoft Teams video). - Scheduled Weekly Hours 40 - Employee Type Regular - Work Shift Day (United States of America) We'll put as paragraph. Now ensure we don't include any boilerplate like EEO statement, competency framework, etc. Let's craft final HTML. Be careful to escape any special characters? Not needed. We'll output:

  About the role

  Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage. Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills. We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more. 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.

  Responsibilities

  • In conjunction with other appeal team members, ensures that clinical/pharmacy appeals and grievances are resolved in a timely manner 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