Senior Nurse Reviewer

Senior Nurse Reviewer

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

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.

Essential Functions:

• 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

Skill for Success:

• It is essential that the candidate possesses strong appeal writing experience, as this skill is 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.

Working schedule:

• Remote, M-F eastern standard business hours. Requires a quiet, secure, HIPAA-compliant working station

Pay Range: $79,560.00 - $115,720.80/Annual

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth.

EEO Statement:

0100 Mass General Brigham Incorporated is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources.