Clinical Appeal Nurse

About us:

Fallon Health is a company that cares. We prioritize our members-always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation's top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs-including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)- in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief summary of purpose:

The Fallon Health Appeals and Grievance process is an essential function to Fallon Health's compliance with CMS regulations, Medicaid, NCQA standards, other applicable regulatory requirements and member expectations. Under the direction of the Director, the Appeal Nurse represents, manages and oversees second level appeal cases (Office of Medicaid, Board of Hearings) and ensures compliance with appropriate regulatory standards. These appeals are in response to determination for medical items or services related to benefits or other related matters that are requested and the application of clinical criteria and medical necessity determinations. The Appeal Nurse is responsible for ensuring compliance with all applicable state and federal laws and regulations governing the work requirements.

The Appeal Nurse is also responsible for presentation of the member appeal to the Plan Medical Director, Center for Medicare/Medicaid Services, contracted reviewer, and the Plan contracted external review agency in accordance with applicable laws, organization policies, and regulatory requirements. Thorough research, detailed documentation, and a well-defined corrective action plan must be developed for each individual case, with all effectuation carried out in full compliance with applicable regulations, policies, and standards.

Primary Job Responsibilities:

Case Review and Preparation

Analyze appeal cases involving denied, modified, or terminated services.
• Review member medical records, prior authorization documentation, and internal appeal decisions.
• Ensure all relevant clinical and administrative documentation is complete and accurate.
• Create and review hearing packets.
• Prepare a clear and defensible case presentation aligned with MassHealth regulations and Fallon policies.

Representation at Hearings

• Serve as the official representative of Fallon during Fair Hearings.
• Provide testimony and present the Fallon's position to the hearing officer, including clinical rationale and policy justification.
• Respond to questions from the hearing officer and member or their representative.
• Submit additional documentation if requested during or after the hearing.

Regulatory Compliance

• Ensure all appeal activities comply with MassHealth Fair Hearing regulations (130 CMR 610.000).
• Adhere to required timelines, including submission of documentation and response deadlines.
• Maintain confidentiality and professionalism throughout the hearing process.

Coordination and Communication

• Collaborate with internal departments (e.g., UM, PA, medical directors, legal, compliance) to gather supporting information.
• Communicate effectively with MassHealth staff, hearing officers, and member representatives.
• Coordinate pre-hearing resolution efforts when applicable.

Documentation and Report

• Support policy, procedure, workflow and performance improvement activities, as related to BOH decisions and trends, regulatory requirements and/or changes, and team case review outcomes.
• Administrate Fallon Health Standard and Expedited Appeals Processes as outlined in Member Handbook/Evidence of Coverage, and in compliance with applicable NCQA standards, CMS, MassHealth and other state or federal regulatory requirements. Strict adherence to department turnaround time standards, established in accordance with regulatory standards, is required.
• Work with Director and management team in developing and implementing specific work plans for improvements in department work processes.
• Serve in a senior capacity providing guidance, training, and/or assistance to staff regarding processing of BOH appeals.
• Commands overall understanding of Department goals and processes. Understands interdepartmental processes and relationships.
• Special projects as assigned by Director.

Education:

Bachelor's Degree in nursing, or equivalent.

License:

Active and unrestricted licensure as a Registered Nurse in Massachusetts.

Experience:

Three to five years of related work experience including state/federal regulatory agency and three to five years clinical experience in utilization review, appeals, or case management within a healthcare or managed care setting.

Previous experience in Home Care preferred

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.