Job SummaryThe 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
Additional Job Details (if applicable)Remote TypeRemote
Work Location399 Revolution Drive
Scheduled Weekly Hours40
Employee TypeRegular
Work ShiftDay (United States of America)
Pay Range$79,560.00 - $115,720.80/Annual
Grade7
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. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.
Mass General Brigham Competency FrameworkAt Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.
